HomeMy WebLinkAboutHealth Permit # 5/14/2015 Commonwealth of Massachusetts Map-Block-Lot
106.BO054
BOARD OF HEALTH -1----------- ----------
Permit No
North Andover -BHP-2015-0192- - ----
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FEE
$250.00
-----------------------ISPOSAL WORKS CONSTRUCTION PERMIT
Pennission is hereby granted James Kellett
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to(Upgrade)an Individual Sewage Disposal System.
at No --1-5-5-0--SALEM.STREET
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as shown on the application for Disposal Works Construction Permit No. BHP-2015-019 Dated May 14,2015
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Issued On:May-14-2015 BOARD OF HEALTH
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nli l/I iii/:" I I ion r I Disposal Sygfgm TODAY. DATE ��., c� 15
Construction Permit - TOWN OF
" 500 Full Repair
'�" Q1 -Component
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 'Repair or replace an existing on-site sewage disposal system* Mk( 1 1
only the tab key
to move your ❑ Repair or replace an existing system component®What? )@ I HN`41) `VER
cursor-do not
Use the return A. Facility Information
Address or Lot#
VQ t I LA ,8� A,,/,'1)0 s,) , (1_,
City/Town
ems" .-*TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump Gravity(choose one)
***If pump system, &Xtach 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)
❑ Pressure Dosed(D-Box Present)S.A.S.
Y ❑ Does the system require an effluent filter? Yes 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)
What is the Make? What is the Model?
2. Owner Information
-
Name -
Addr ss(if different from above)
City/Town �y7 State Zip Code
mail address Telephone Number
3. Installer Information
Nam __---- ..w... `"" N x., Jp°_ y r LL / dF Q Mm,mm✓
p e Name of Company
Address
City/ wn a
l t/ Sy M ��� 6
to ® r Zip Code
Telephone Number(Cell Phone#if possible please)
4. Desbb iC netr /Information /
tz.•l K./ �..,. 4./� °4../''�f C..tr7�4..4:'11
Name / Name of Company
C
Address
1 c.:' �;� Code " .
ity/T n � _ State w o� .,. �' Z�, .w r�'�.., �.✓-
� 1 (, 1, ('5 (`
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
ti on for Septboc Disoosal y t
TODAY'S DATE
Construction Permit — TOWN
NORTH 01845 26.00-Comp Component
PAGE 2 OF 2
A. Facility Information continued....
5. 11 a of Building: Residential 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 hat un i a final Certificate of Compliance has been issued by
�ithi Board of Health Ih ins
edsystem is not approved.
Al
Na Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use
1. Fee Attaclieda Yes No
2. Project Manager Obligation Form Attached? Yes No
3. Prxtnp Svstem? If so,Attach cop=y of Electrical Permit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed approval letter, all paperwork received. Yes No
1Vlisstn
5. Foundation As-Bttilt?(new construction only): Yes No
(Same scale as approvedplan)
G. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer: for the construction for the septic system for the property at:
(Address of septic sysi m) For plans by f (1 J� d a�/ Pfi � 0 /` (),!V
Relative to the application of ), c
(In °� �,( And dated
Dated )"
o a s(.Lrtc With revisions dat ed
(Last rcm ecl daue')
I understand the following obligations for management of this project:
1. As the installer,I am obligated to obtain all permits and Board of Health approved plans p1ior to
performing any work on a site. I must have the approved glans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
MY company
a. Bottom of Bed—Generally, this is the first (V inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc.
As-built of verbal OIL (or e-mail to: hc;dlhda pf frlo th,ft.cic»rK ,°, t;l:) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work(other•than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used,
c. Final inspection by Board of Health staff or consultant.
d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other
components,
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve
me of this obligation, " ",i r i S, 2--0 5
Undersigned Licensed Sep tic Installer:
.._ .._ (Today's at ')
"J'q/,t" t.
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