HomeMy WebLinkAboutHealth Permit # 6/18/2014 ° �, Application for tic i Sai y stem
Q� �,.u.0 TODAYS DATE
Construction Permit — TOWN OF
ORTH ANDOVER, $ 250.00—Full Repair
� .A.OW 5�`'M 01845 $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
Y y ❑ Repair or replace an existing on-site sewage disposal system
Y Repair or replace an existing system component What?
computer,use * ,��•
only the tab ke < `
to move our IE,I
cursor-do not
use the return
key. A. Facilit y Information
l—Y "
rob Address or Lot#
City/Town
2.-*TYPE Ok SEPTIC SYSTEM*:
❑ Pump 2 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
Address if different from above)
City/Town S ate Zip Code
Telephone Number
3. Installer information,
.
Name.-- Name of oC' mp
City/Town G Zip Code
D
V2,1 (,-, 2
Telephone Number(Cell Phone#if possible please)
4. Designer Information
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
µORT3,OF°, Application for Septic Disposal System T ! �-
"9ti
3a v.o O0
TODAY DATE
° pConstruction Permit — TOWN F
ORI" ANDOVER CIA 01845 $250.00—Full Repair
�9SSacNUSE�ty ® $125.00 -Component
PAGE 2 OF 2
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
No rt n ov r, not t place the system in operation until a Certificate of Compliance has
bee s e b Health,
e Date
Application f proved By: (Bo of Health Representative)
Name,..-" ( Date —� �
Application Disappro ed fort e following reasons:
J'
For Office Use Only:
1. Fee Attached. Yes No
2. Project Manager Obligation Form Attached. Yes No
3. Pump System? Ifso,Attach copy ofElectrical 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:
z"'.)/;y f�
(Achira s",of se ptk System) For plans by
Relative to the application of -0 1� � � � �f A) ���
(ln t:allc.'s rraorac",Y nd dated
F
(t..t'S&.ptnrr (Lt tc
Dated 6 ZI(T ZI
y date) with revisions dated
(LI"t rewased cUe)
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 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.
1 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: litlt �,est er >vr7��rf't;�e�t l'f.�ilzad<rc<:f'.crr�a7,) from the engineer must
be submitted to the Board of Healah,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 tban sililple excen)crtion)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 er the
approved plans. No instructions b th homeowner. neral contractor, or an other persons shall absolve
me of this obligation. V_
Undersigned Licensed Septic Installer: t (Today's Date)
xne ,rant) af c . Signed)
Map-Block-Lot
Commonwealth of Massachusetts
BOARD OF HEALTH ____ _____
Permit No
North Andover
FEE
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted �
to(Repair)an Individual Sewage Disposal System. r
at No 4Y 41 Al -t ct,
-------------------- -- -- -------- — -------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. Dated
Issued On:
-- —
B ALTH