HomeMy WebLinkAboutHealth Permit # 10/26/2012 . k � Commonwealth of Massachusetts Map-Block-Lot
106.D0067
BOARD OF HEALTH PermrtNo
North Andover BHP-2012-0752
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P.I. FEE
F.I. $250.00
DISPOSAL WORKS CONSTRUCTION MIT"
Permission is hereby granted Todd-Bateson
to(Repair)an Individual Sewage Disposal System.
at No 75 WINDSOR LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2012-075 Dated—October 26,2012---
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Issued On: Oct-26-2012 BOARD OF HEALTH
Oo r tip u n
I TODAY'S DATE
, ...w. .
Construction Permit — TOWN
ik
4Y
m �
ORTH ANDOVER. MA 01845 $ 25o.a0 M=ull t2epr
$125.00-G . pWi6rit
Important: Application is hereby made for a �►ermit to:
When fining out ❑ Construct a new on-site sewage disposal system
forms on the
computer,use 0"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 A. Facility Information w
key. ��., RECEIVED
Address or Lot#
- --- ---- -- - - - -- --
�w
— TOWN OF Nt'"f"I�ANDOVER r�r�vn City/Town - -
2.- *TYPE OF SEP'T'IC SYSTEM*:
❑ Pump ® 'cavity (choose one)
***If pump system, attach copy of electrical permit to application**
❑ Conventional System (pipe and stone system)
❑t''r4filtrator or Biodiff user(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
G
Name
/6
- - - -
Address(if different from above)
City/Town – State Zip C f
y ode
Telephone Number
3. Installer Information
Name - Name of Compan ®> N t
ARa,111A[10
NTERPRISE ,INC.
Address
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information p
Name Name of Company �t uc la
Address
City/Town State Zip o
--
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
G`Tr'■j°RTN Applicati-oh. Septic Disposal :System
�1No -
3= TODAY'S DATE
F A Construction -Permit TOWN TOWN OF
.250.00-Full Repair
* °* •.��w�� -ORTH ANDOVER, MA 01:845 $
^�H�S ch :� $125.00-Component
PAGE 2OF2
A, Facility.lnformat9o.n continued....
5. Type-of Building: Q esidential Dwelling or[]Commercial
B. Agreement
The underslgned agrees to.ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been Issue y this Board of Health.
Name Date
Applicati h Approved By"(Board of Health Representative)
Name' j Date
�'�
Ap�lic tion Disapo oved r the following reasons:
For Office Use Only:
1 Fee Attached? Yes_ No
2- Projectll?abager Obligation Form Attached. Yes No '
3.: Pum,p SYS—, Ifsol Attach copv ofElectrrcal Permk. Yes No
4. FoundadouAs Bur'lt.?(hew construction•ronly)r Yes_ No
(Same scale as approved plan)
.5 F1oorPlans?(new construction only). Yes_ No
Appifcation'f�rp(spQ§al
4ystem--06n6truction Permit;Page 2 of 2
SEPT IC SYSTEM.IN$T�I;Ek PROJECT MANAGEMENT OBLIGATIONS
As the-North Andover•licensed installer for the construetipn for.the septic system-for.the•propetty.at:
u G"i„'1`0 t' .5ce':L_ 1 7r,F y.c.. '"tivt /� ! /'fr/Et`ul idxCil
For plans by / {-----
(Address of septic system) (Engineer)
Relative to the.application of �z.� '`
(in'staller's name) Aad dated
rigina ate .
Dated Id, 1, With revisions dated
( 55 s ate) (Last revised date)
I understand the following obligations for management of-this project:
1. As the installer, I ami.obligated to obtain•aU permits and Board offHealth approved plans.PILOT to
;performing any:work on a site: I must have the anbroved'ylans and the yermit'on site when anv work is
hero—
2. As the installer,.I must'call-for any and alkinspections: 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 ihree•shill•be.applicable.
.`' As•tlie'Astaller;I.atz1 required to.have.tlie necessary work'eQmpleted.prior to the.applicable inspections as
itidieated below. I tifrdefstand that re�ue'stinn�an inspection without.comyletion:of the itetns in.accordance
with Title 5 and the Boafd of ealtli Re tibns tray resultin a$50'00•- e'beine levied aeatnst:me..and/or
'my eotnpany:
a : Bo'tforii of•B.ed' Generally,fl iris the first 1' :in's ection pnless,there is a retaitiin wall,which
� � . p . . g
shotilii'be.do ieA. st: T1ie;uistaa-, niust�.Cques#die iiispectiozi but does•riot have to be ptesent. .
b. Final-Consiruct ori.Inspeetioti—Engineer mu 't-firsi;do their ii�speetion for elevations,•ties, etc,
As-buile of v'erhal OK(or e-mail•to:liealtldep 'townofnorthandover.com):from the engineer mast
•be subniitfed•to*-.t�e.BQ'ard'of Health,ai'ter.*-wL6h:mstaller•tails'for:an inspection dme. Installer must
be present for this.inspection, With-a pump.system;all electdcal•wotk.,tnust be ready and.able to
causepump.to-v�ork grid alaimiao fiuietion..
c. finafGtade---Installer must request inspection wheli'all grading'is'complete._ Installer'does not
have to be on-site. '
4. As-the installer,'I understand that only I may pezform the work(other than:dm,ple excavation)and I am required
to coffiplete the installation of the system identified in th&.attached.application for iristallation:.I farther
unders;and•thatwork doneliv others unlicensed to'instaII+,elitic systemsin North Andover cat!con8titate
reasons for denial-of the'systetn andlor.'revocatiotl-or su§ etision of•rny licenseao operate in.the Town.of
North Andover,sificant fines tQ allersons in'volvetl are also possible
5.. As tlie1nstiillerJ understand thafl m`u_ASe**on-.site during the-per f6*ance.of the-following construction.
steps:'
a: Detemunatrori tbat.tbe proper•elevation ofthe'ekeavation has been reached
A Inspection of the`sand and store-to be used,
c. Final mspectionr by Board ofF,Iealth stiff or consultant.
d. Installation,oftank DBox pipes,stone, vent,primp chamber,retaining wall and other
components.
6. As the installer, I•understand that I am sblely responsible for the installation.of the.system as per the
ap roved:lilans No instructions by the�hotnemaer. general.contractor_-or•any.6ther,12ersons shall-absolve
me Qf'this obligation.
Undersigned Licensed Septic.Installez: ` (Today's Date
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