HomeMy WebLinkAboutHealth Permit # 11/6/2013 e �
Map-Block-Lot
Commonwealth of Massachusetts
038.00118
BOARD OF HEALTH Permit No
North Andover -BHP-2013-10
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P.1. FEE
F.I. $250.00
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Todd-Bateson
to(Construct)an Individual Sewage Disposal System.
at No 285 REA STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2013-102 Dated November 06,2013
----------------------------- --------
Issued On:Nov-06-2013 BOARD OF HEALTH
Iic tion for Septic Disposal Svstem
P' TODAY'S DATE
Construction r i
NORTH ANDOVER, MA 01845 $ 250.00®Full Repair
$125.00-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*
only the tab key
to move your E] Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
ke y. w _
,..
Address or Lot dl
City/Town -— N J
2.-*TYPE OF SEPM S'iYS1'EW:
➢ ❑ Pump Pump ravity(choose one) I it X41 i t i iaEi Ala CW i i i
***If pump system, attach copy of electrical permit to application*** �
> ❑ C ventional System (pipe and stone system)
➢ n iltrator 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.
➢ ❑ 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 DWC issuance)
Wiatis the Make? What is the Model?
2. Owner Information
Name
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name-------�--/----
„
------ �Name Comp"
EJ-pnlSi7�,' INC.
(/6 T
Address -
City/Town State Zip Code
Telephone Number(Cell Phone#if possible p
--- --- please) ---
4. Designer Information
. + -i-K,-q ? rtmc
Name Name of Company
Address ----
_..
�
f` - -- ----
State / Zip Code
6iv �
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit.Page 1 of 2
Application for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF
NORTH ANDOVER, MA 01845 $125 00-comp event
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: e- idential 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 H911th, the installed system is not approved. /
Name Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
L Fee Attached? Yes No
2. Project Manager Obligation Form Attached. Yes No
3. Pump System? Ifso,Attach cony of Electrical Permit Yes No
4. Reviewed approval letter, all paperwork received. Yes No
Missing.•
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
6. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEP'Z'IC-SYSTEM.INSZ'A XE"—PROJE'CT NIA��GEMEN'� �OBLIGA'I'IONS
As the-North Andover•liceaisedanstaIler for.flee.c6n'struction for:theseptic syste.tn':for.the-propertyat:
, ? in s+ "f ;�(� y�r✓ w61 .
For plans by m
(Addresi of septic system) (Engineer)
Relative to the.application of ,;-- Acid dated -°
(in'staller's name)
rigina Gate).
.
Dated G 6" With revisions dated
klodays a e (Last revised date)
I understand the following obligations for management of•this project: ,-
I As the installer,I am.obligated to obtain•all per. its and Board of:Health approved plans.prior to
;performing any'work on a site: I must have the a provedtilans and the permit:on site when any wozk is
A
biinZ done
2. As the installer,.I.must'•call•for any and A-inspections: I£homeowner,contractor,,projectmalinger, or any
other person not associated with my company schedules-an inspection and the system is not ready,then
item three•shal be.'applicable. „
.` As.thp astiho,•I�ati•xttl fired to.have.the ptecess ry work'coInPI d piior,to the.applicable inspections-a
indicated belowY, T k;a• j�stawa'that r Q�6�� ,;sr,S�n withot�f comli'letioit of the jttn�s in accorclarice
aua.aausaau uaa�se'
l e s me..iti r
a.. Bo't otn bf-8.eti Generally,tl is-is thc'bxs: .�1'�:`i?�'speotion unless.there is a'retaining wail,Which.
shQcl.bc dtti ie<first: lfiic'uistall triusC eques#die iiispec46a but does—riot have to be present: .
eti'o titpeeti ori—Engineerlhusrfirst do theit<inspecdon for elevations,••ti`es,'etc.
As-l�iiilt of desbal OK (or e-mail•to:healtlid�nto 0 othanclover.�oml from the engineer must
be subiriitfed to'.t1ze,Bo'ard'of Health,aftex:wldeli:installer•sails fgx an insp'ectipn time. Instiller must
be present for this,inspection, With•a pump:Sy$t m,•all•electrical•wotk;musf be ready and able to
cause pun7p to arork acid Alarm''to funivtion..
c. �FindlI Gmdt•—installer must request inspection tvheii 4 grading-is'complete:..Installer'does not
" have to be'on=site.
4. As the installer;I understand that only Imacy pexform the.3aorlc rotberthan rimple excavation)and'I Ai required
to complete the•installation of the system identified in they:attached application'for in'stallation :Ifurth'e
undc nd-that work done'�y.otli'ers ui- i'censed tQ iris se 'tic.systems•in North Andover sate constliiite
reasons for derial-of the•syste_m andl6"evocation;o�u'men'sion o f rnv license•to opetate in.the Town of
North Andover.`simificant fines.Xo all rsonyetj are also pos's'ible.'
5..
As the.inst
stiller,,I understand that'l muft'bc orl-,site searing th .ptxfoxtriance of the-following construction
steps:'
a: Defemz&adont that,theproperelevadon of the'eXrcavation has-been reached
b. Inspee oa of Me°sand and swde-to be used.
c. Pinal inspection by Boarof of.Fealth staffor consultant.
d. Installation:.•oftank,D-Box,pipes,stone, vent,primp charmbet,r&R4.ILrrg wall and other .
components.
6. As the installer."I WW rstand that Lam sblfjy r,se ppnsibl2 for the installation of the system as per the '
gpl p and No instructions by the�om gtneral conira= nr ley otiiPr perann� ���ll absolve
me Off1iis bbliegdgn.
Undersigned l::iceased S ptic.In
e stallex:
l.'. 11vi L'•.... :L b