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TODAY'S DATE
Construction Permit t — TOWN OF
re° * ° ' $ 250,00® Full Repair
$125.00 - Component
Important: Application is hereby made for a permit to:
When filling 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
cursor-do not
use the return A. Facility Information
y r
'.
cab Address or Lot#
ewn City/Town
2, *TYPE OF SEPTIC SYSTEiVI*:
❑ Pump cavity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
Infiltrator or Siodiffuser(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 _v 6, t '
Address if different from a
*, Y' (' b t, .
} " c') I
City/Town / Y - State Zip Code
--- ——.._.__ ---------
Telephone Number
3. Installer Information
Name Name of Company
.. ..zi. ... ,' .
Address
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
^ " Cwt
4. Designer Information eO3
( . a L ' r;S` _ .w) „ c.a��t__ r�.i.
Name Name of Company
Address
C > "
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Of V,°RTH Application for Septic Disposal System
-- TODAY'S DATE
Construction n Permit
°I' 01845 $ 250.00-Full Repair
$125.00-Component:
SSACHUS�
PAGE 2OF2 .
A. Facility Information continued....
5. Type of Building: Residential Dwelling or ❑Commercial
B. Agreement
The undersigned agrees to ensure the construction an 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.
`2")Cam- -V l b � a-- C
Name Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Project Manager Obligation Form Attached? Yes No
3. Pump S. stem? If so,Attach copy 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
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of tine septic system for the
property at �° � �. trw relative to the application
�)"1°- 1�����. .�� �n_ �� �.�� fir. for plans by".��
of a � ��.r y' 'Ied
dated �, S' with revisions dated � �� � ('15 o
I understand the following obligations for management of this project:
I. 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 approved plans 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
manger, 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 tine applicable
inspections as indicated below. I understand that requesting an inspection, without
cornpletion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a$50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or
verbal OIL from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection, With 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. Does not have to be
on site.
4. As the installer I understand that only I may perform the work(other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work 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.
Undersigned a Licensed
Sept rJ,,'st'a'ller
Date: