HomeMy WebLinkAboutHealth Permit # 11/10/2005 Map-Block-Lot of Massachusetts
105.D-0068-
4
Board of Health
Permit No <,
q North Andover BHP-2 00 5-07 15
o
P.I. FEE
F.I. $125.00
Disposal Works Construction Permit
Permission is hereby granted JOSEPH R. WATSON
to(Repair-TANK ONLY)an Individual Sewage Disposal System.
at No 1 SCOTT CIRCLE
as shown on the application for Disposal Works Construction Permit No. BHP-2005-071 Dated November 10,2005
ti
-
Issued On:Nov-10-2005 -�
Board of Iealth
. .....
q Commonwealth of Massachusetts Map-Block-Lot
105.D-0068-
Board of Health'
North Andover
Certificate' of Compliance
•rr, e' q.
THISIS TO CERTIFY,That the Individual Sewage Disposal Systerq ONLY)
by JOSEPH!R. WATSON
-------------- ---- __
-- --- - - --- ------
Installer
at No 1 SCOTT CIRCLE
— ------------------------------ ----------- -- - ---- - — -------------- -- ---- - -- --- -----
has been installed in acco ce with the provisions of TITLE 5'of the State Environmental Code as described in the
application for Djsp sal Works Construction Permit No. BHP-2005-071 Dated November 10 2005
- - - - - ----
--- - ---- ------------------------ --------Printed On.'Nov-1- 2005 Board of Health
........ . ........ ......... ........ ....... ... ....... ........`. ......... .......: ......... ................... .......... ...... : ....I.... .....r... .........
� µ lic tiro for S 3tic t ,o
TODAY'S DATE
m
Construction Permit — TOWN OF
NORTH A 01845 -gun Repair
.� X125 00 momponent
Important:
Aoolication is hereby made fora l2ermit to: "
When filling out El forms on the construct a new on-site sewage disposal system*
computer,use ❑ Repair or replace an existing on-site sewage disposal system* i a
only the tab key
to move your 15I,epair or replace an existing system component �.�
cursor-do not ........
use the return
key. A. Facility Information
..� "
r Address or Lot#
City/Town
2.-*TYPE OF/SEPTIC SYSTEM*:
❑ Pump Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
Conventional System(pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Sox) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Sox Present)S.A.S.
2. Owner Information
Name
Address f different from above)
-- --. �. w, y a '=
A112 14'111,9 Ll e P
City/Town State Zip Code
Telephone Number
3. Installer Information
t ,rw - _
�� Name f Company
�. �. �` �. . <,,,
Name .,
_ p W
Address _-. -- ... — --
Cityrrown State Zip Code
" 9 e'7 _
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address _
— -----------------
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for Septic Dispos I t
TODAY'S DATE
Construction Permit — TOWN OF
s� , 01845 250.00-Full Repair
$125.00 a Component
PAGE 2OF2
A. FacLlity Information continued,...
5. Type of uildina:� Residential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and-mmilintenwitre of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
North Andover,and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
Names � � �
"4014Y b Date
R catio li Approved A roved fay: ( ,ard of Health Representative)
Name" Date
1pplication Disapproved for the following reasons:
For Office Use Only:
Z Fee Attached? Ye ;°"""w..,., No
2, Project Manager Obligation Form Attached? Yes No
3. Pump Sys ? If so,Attach copy of Electtical Permit Yes No
4. Foundadon As-B'uilr?(new construction ronly): Yes_ No
Game scale as approved plan)
5. Floor Plans?(new construction only): Yes ",....- No
Application for Disposal System Construction Permit-Page 2 of 2