HomeMy WebLinkAboutHealth Permit # 4/2/2014 n�}
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Commonwealth of Massachusetts Map-Block-Lot
Illl/1 %v ° 104.A0089
io - ----------
• Permit No
North Andover BHP-2014-0492
FEE
$250.00
DjspOSAL WORKS CONSTRUCTION I`?
Permission is hereby granted Chad Jablonski-------------
to(Construct)an Individual Sewage Disposal System.
at No 730 WINTER STREET___ __ ____
as shown on the application for Disposal Works Construction Permit No. BHP-2014-049 Dated I
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Printed On:Apr-02-2014 -------- _ — !B(J O ILLT 1
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ORTH
Repa' )
Important: Application is hereby made fora permit to:
When filling out onstruct 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
rah Address or Lot#
A'l, 4
turn City/Town
2.- *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) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
Name
a
Address(if different from above)
lam . ✓k ✓` aJ' Jc C� �✓ ` Jytt��
City/Town State Zip Codes
----- — G ) t C)
Telephone Number
3. Installer Information
c t`r
., .�
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Cell Phone#if possible lease)
4. Designer Information C
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for ptic i I Y to
Construction Permit TODAY'S DATE
ORTH $ 250.00—Full Repair
ANDOVER a $125.00 o Component
PAGE 2 OF 2
A. Facilitv 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 dover, an not to place the system in operation until a Certificate of Compliance has
be iss dy th" Board of Health.
Name Date
Applicati n 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 OhAgation Faim Attached. Yes No
3. Pump 5ystem? If so,Attach copy ofElectrical Permit Yes No
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floof 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' e°ptic yslern) For plans by
(1 ra;toleer)
Relative to the application of C �LA
(Ins ,er's nattne) And dated
j z 1gina date)
Dated ® - !Y
1 ,r as �d spew with revisions dated
(lsnst revised dale)
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 rp for 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 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 ('1'`) 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: lac t h,hc.ltl t"(t)tCxwK t>EnorthandR vcrr.g.«mj) 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 an other ther persons shall absolve
me of this obligation.
M
Undersigned Licensed Septic Installer: odf, 1' 1_)ste)