HomeMy WebLinkAboutHealth Permit # 9/26/2006 a°RTM
A�® Commonwealth of Massachusetts Map-Block-Lot
037.B-0036-
Board of Health -----------------------
Permit No
tU North Andover BHP-2006-0260
4a.•,.,.s.i� P.I.
-----------------------
F.I.
FEE
�SSacw�s�t $250.00
0.
Disposal Works Construction Permit
Permission is hereby granted
to(Construct)an Individual Sewage Disposal System.
at No 415 SALEM STREET
------------
as shown on the application for Disposal Works Construction Permit No. BHP-2006-026 Dated September 26,2006
i
Issued On: Sep-26-2006 - r ----- -------------
�—�Ard of I4ealth
TOWN OPNORT1111ANDOVER
Office of CONNIMUNI'll' WEVELOPMENTAND SERVICIP"s
HEMLI'll DEPMRTMENT
1600 t) l) 1ORPT'I'; R(JILVNG 20; S[JFUK 2-36
NORTI I ANDOVIT, MAS,15A(A 1USFAI'S 0 1845
978,689,9540 Phone
Susan V.�Saivyer, RETIS/RS 978'.W04'761 FAX'
Pubfic Health Director c nad
websi e
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:
LOCATION:
HOMEOWNER NAME: r WA
T
"
LICENSED INSTALLER NAME: c.' )� ,- �
PLEASE PRINT
SIGNATURE: TELEPHON
/) ,/ )� E#
........................................ ...... ......../............................. .............................
CHECK ONE:
FULL SYSTEM REPAIR: ($250)
COMPONENT REPAIR(indicate what parts): ($125)
• NEW CONSTRUCTION: V
• If NEW CONSTRUCTION,please attach the Foundation As-Built Plan.
................ .......... ___...................
$250.00'or$125 Fee Attached? Yes No
Project Manager Obligation From Attached? Yes No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval of Health Agent Date:
TOD Y'S DATE
,Construction Permit
$ 250.00—Full Repair
4"
SA GNUS $125.00 - Component
t
Important: Application is hereby made fora Permit to:
When filling out stem*
Construct a new on-site sewage disposal s
forms on the g p y
computer, use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key g g p y
to move your ❑ Repair or replace an existing system component
cursor-do not
use the return
key. A. Facility Infor�atio
�Iy'j�O�It Address or Lot# — ------ _
/V' --
enun City/Town
2.- *TYPE O " 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 Informatio
Name
Address(if differebove) — --
Ciiy/Town -- State — - Zip Code ---------
Code
Telephone Number - --
3. Installer Information
Name �� � — m ---
f) P"� �������Ed/�Y/ Name of Company
Address ���
City/Town State � �------
Zip Code
Telephone Number(Cell Phone#if possible please)
4. Desi ner Information
Name
Name of Company
Address
6 t if Tcow_n :22pll jo��/
State Zip Code
Telephone um er(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
9i tl o for tl I I
t'r j4 TODAY'S DATE
",,Construction
w � � Permit - TOWN OF
j $ 250.00® Full Repair
T 01845 $125.00 - Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Build ing: 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 Cade, 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 �this Boa Wealth,,.,..
r ,e
Name Date
Applicatiar,5 p peed By: (Board of Wealth Representative)
p m..
Na, - r° Date
//'Application Disapproved for the following reasons:
For Office Use Only.
1. Fee Attached? Yes No
— — 1
2. Project Manager Obligation Form Attached? Yes=......` No
i
3. Pump S� sy tent? If so,Attach cap,�f Electrical Permit Yes r° "'" f No
4. Foundation As-.Built?(new construction ronly): Yes � °,._- No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes Na_
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:
(,Wdra ss of se ptk spsIon) For plans by (
s l axt t
Relative to the application of /1 6<,"o
(lrttitalk"r:'s nalne) And dated
nt;