HomeMy WebLinkAboutHealth Permit # 6/30/2015 (2) ----------------------------------- _
Commonwealth of 11�assachusetts ---�--- — -
°a Map-Block-Lot
BOARD OF HEALTH 106.A01 38----------------
Permit No
P.I.
North Andover BHP-2015-0289
F.1. ------- FEE
--------
$250.00
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Jahli Butt
to(Upgrade) an Individual Sewage Disposal System.
at No 1353 SALEM STREET
----._----
as shown on the application for Disposal Works Construction Permit No, BHP-2015-028
Dated June-30,201-5
Issued On:Jun-30-2015 ------�- __--
-
— ------
. _ _ ----BOARD'OF
IMEALTH
tion for Se tic Q sposal Syptiam i L� (�'� �x")
Construction Permit — T TaDA�vus ATE
.0M;'A'
NORTH ANDOVER. MA 01845 Etall Repair
®a0 a'mponent
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer, use E] Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your El Repair or replace an existing system component®What?
cursor-do not
use the return A. Facility Information
key,
Address or Lot#
City/Town
emn .- *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-Box)
A Pressure Dosed (D-Box Present)S.A.S.
> ❑ Does the system require an effluent filter? Yes t" No
If yes, does plan specify make and model of filter? YES=(no further info. needed)
NO=(installer must specify brand of filter before®WC issuance)
Wliatis the Make? a"�" �` '.1�.,. WliatistheMoclelP
2. Owner Information
Name
k
Address(if different from above)
CitylTown State Zip Code
Email address Telephone Number
3. Installer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone hone
Number(Cell Phone#if pabsible please)
4. Pesianer Information
e
0l
Name , N e of Company
d�
k
Address
w Y 0
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
tin for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF
NORTH ANDO A 01845 $250.00®Full Repair
$125.00- Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: oResidential Dwelling or ❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance 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. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approved.
dry q L 2
Name F' Date
p rd deallif Representative)
Ap proved By: (Boa
tame Date
Application Disapproved for the following reasons:
For Off ice Use r�nld:
Z Fee Attached? Yes No
Z. Project Manager Obligation Form Attached? Yes No
3. Pump Sys ? If so,Attach copy ofElectrrcalPermit Yes No
Applican t received copy of
"Electrical Inspection Notes for Septic Systems" Yes , No
Ilandout.P
4. leviewed approvalletter; allpapenvorki-eceivedP YesL111 No
Missing:
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
G Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit^Page 2 of 2
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