HomeMy WebLinkAboutHealth Permit # 11/9/2010 Map-Block-Lot
Commonwealth of Massachusetts
106.B0012
Board of Health PermltlVo
North Andover BHP-2010-0758
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P.I. FEE
�S AC Usf� F.I.
$250.00
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Todd_Bateson
to(Repair)an Individual Sewage Disposal System.
at No 1907 SALEM STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2010-075 Dated November 09 2010
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Issued On:Nov-09-2010 Board of Health
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,0°RT#j Application for Septic Disposal System i
Construction Permit -TOWN OF
ORTH ANDOVER, MA 01845 $250.00—Full Repair
�,,��•�' $125.00-Component
SACµ0S
Important: Application is hereby made for a permit to:
When flung out — El Construct a new on-site sewage disposal system*
forms on the
computer,use Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑Repair or replace an existing system component—What?
cursor-do not
use the return
key. A. Facility Information
ITV Address or Lot# si
N s ,� �ry
Cityrrown /� �'
2.-*TYPE OF 19EPTIC SYSTEM*:
❑Pump ff 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) (Attach Draft Maintenance Agreement)
❑Pressure Dosed(D-Box Present)S.A.S.
2. Owner Information
Name
/ 11 "7
Address(if different from above)
Citylfown - AA
State
Zip Code
7�—
Telephone Number
3. Installer Information
®--T,,dJ
�
Name Name of Company 111 AR(3ILLA ROAD .
/ lc / r-4- ANDOVER, MA 01810
Address
Cfty/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
,
Name
Name of Company
Address
Citylrown ®/ 5�'1
State Zip Code
�7
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit page 1 of 2
N°aTH
Application for
° TODAY'S DATE
w A n tr ti r it — TOWN OF ,
ORTH ANDOVER. MA c $ 250.00-Full Repair
��s'sACHUS K� $125.00 -Component
AG
A. Facility,Information continued....
5. Type 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, and not to place the system in operation until a Certificate of Compliance has
been issued this Board of Health.
s
Name Date
A ppllcatlD p A�p ro-v e d By: oa r d�of Health Representative)
ve)
A ,
Name,-° "„ '" Date
Applibation Disapproved for the following reasons:
For Office Use QpI
I Fee Attached,? Yes No
2 Project Manager Obligation Farm Attached.? Yes! No
9, Pump System? If so,Attach copv of Electrical Permit Yes
No
4. Foundation As-Built,?(new construction ronly); Yes No
(Same scale as approved plan)
5. 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:
For lans bat.
(Address of septic system) p y
(Engineer)
Relative to the application of )"4 z.=a �s
(Installer's name) And dated �G
ngma date)
Dated ,f
IocTay's ate With revisions dated
(Last revised date)
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 prior to
performing any work on a site. I must have the a1212roved:121ans 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 (1s)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 OK (or e-mail to: healthdept( t�ownofnorthandover.com) 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 arid.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:rim ple excavation)and I am required
to complete the installation of the system identified in the attached application for installation.: I fiartlier
.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 ate also possible
5. As the installer, I understand thatImust`be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
A Inspection of the sand and stone to be used,
c. Final inspection by Board ofHealth staff or consultant.
d. Installa don.oftank,D-Box,pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely resl2onsible 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 thus obligation.
Undersigned Licensed Septic Installer: (Today's Date) �/�✓°i`°
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(Name—Print)
arr�e ,