HomeMy WebLinkAboutHealth Permit # 11/18/2008 ORYa Commonwealth of Massachusetts Map-Block-Lot
106.A-0152-
�F Board of Health Pemiitrlc
s
North Andover BHP-2008-0221
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d P P.I. FEE
�rqs°4•,. �`
F.I. $250.00
Disposal Works Constructi®n Permit
Permission is hereby granted John_Soucy______________________________
to(Repair)an Individual Sewage Disposal System.
at No 259 GRANVILLE LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2008-0221 Dated.__November_17,2008
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Issued On:Nov-18-2008 Board of Health
x
3= �r;gA-1 Application for Septic Disposal System
° TO Y'S ATE
AConstruction Permit - TOWN OF
* * $ 250.00—Pull Repair
°R r ORTH ANDOVER, MA 01845
$125.00 -Component
9SSACHUS�'�
Important: Application is hereby made for a permit to:
When filling out
forms on the ❑ Construct a new on-site sewage disposal system*
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. Facilit Information
0 t -Jj
_^t Ve t` 0
rab Address or Lot#
iensn City/Town
YPE OF SEPTIC SYSTEM*:
XPump ❑ 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
v � -
Name C / t
Address(if different from a ove)
r
City/Town State Zip Code
Eu� 73
( Telep one mber
3. Installer Information
I
Name Name of Company
L
Addres
Cityrrown fate ff Zip Code
Telepho e Number(Cell Phone#if possible please)
4. Desi ner Information
4xj v
C
Name � Name of Company
Address,GG
City/Town L ~ Stale Zip Cod e k
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
r% nTfj q Applicajon for tip i I y t pa
. ` p n tru ti Permit TOD S D E -
�M;w... , +" $250.00 A Full Repair
`�SACwuS tam � $125.00 -Component
PAGE 2 F
A. Facility Information continued....
5. Type of uildin Residential Dwellin g 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 Andover, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
Name Date
Applic4jdn Approved �y/:(Board of Health Representative)
Nam - Date - - - --
Application Disapproved for the following reasons:
For Office Use Only:
2, Fee Attached? Yes_"� No
2. Project Manager Obligation Farm Attached.? Yes No
3. Pump Svstem? If so,Attach copv ofElectdcal 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:
"a
r
(\ddra ss' of septic system) For plans by
Relative to the[1),hcatioll of V` . t� t °'I ns alley's natme And dated
"Y1T.la iltf��Dated t 0 osr
oc a7, s c ate With revisions dated
(Last revised ate)
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.
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
m 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: healthd -)t(t?,toNvncYfmrthandovcnc;om) 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 tl�an supple excamlion)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 any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: 1 N ("C oday's 1)a
a.Y,tt, - rtri: a Ill e z�ttec;