Loading...
HomeMy WebLinkAboutHealth Permit # 9/9/2014 � Commonwealth of Massachusetts Map-Block-Lot --- ------- --------- BOARD OF HEALTH Permit No • BHP-2014-0692 North Andover -------------_m-- -- P.I. FEE $250.00 F.1. ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Matthew Manniplg-------------------------------------------------------------------------------- to(Construct)an Individual Sewage Disposal System. i at No 64 STANTON WAY \ --------------------------------------- --- ---- -------- ------- -- ------- - ------- as shown on the application for Disposal Works Construction Permit No. BHP-204 069 ated September 09,2014 ------------ ----- ----------- Issued On: Sep-09-2014 BOARD OF HEALTH t � CDi ! µORTfi Application for Septic Disposal S Vstem 6 1,�ol,(Ll ' Construction Permit — TOWN F TODAY'S DATE O1Z'I H ANDOVER, MA 01845 $250.00—Full Repair $125.00-Component 9S©CRUSE' Important: Application-is hereb made fora permit to: When filling out Construct a new on-site sewage disposal s stem* forms on the g p Y 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 key.y the return A. Facility Information r� Address or Lot# /Cleo � V\A A nAnya_�' City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump ravity(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 &eat- Name 167 '1 0SC-1000 S A- Address(if different from-above) City/Town State Zip Code Telephone Number 3. Installer Information Name Name of Company Address A City/Town St Zi Code �- T ho e Number(Cell Phone#if possible please) 4. Desi ner Information W " _ems C C-, CVI n sc..,, 4- Se ceA ' T_�vc � Ngame Name of Company Address Hcive.CV\, 11 AAA Q (`5310 City/Town State Zip Code (q--7q ) 373- 0:> Telephone Number(Best#to Reach) Application for Disposal System Construction Permit°Page 1 of 2 °F H°RTH�ry Application for Septic Disposal System . ° 6 /30/ Y oa a. 'Construction Permit ® 1 TODAY'S DA E OF ORTI-1 ANDOVER, CIA 01845 $250.00-Full Repair . 5 9SSACHUSES $125.00 -Component PAGE 2OF2 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 North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. N>i m,e Date 70/ Application Ap oved By: (B rd of Health Representative) Name Date Application Disapproved f the following reasons: For Office Use Only: Z Fee Attached.? Yes_ No 2. Project Manager Ohligation Form Attached? Yes!-, No 3. Pump S sV tem? If so,Attach copy of Electrical Permit Yes Ne®' 4. Foundation As-Built?(new construction ronly): Yes i No (Same scale as approyed plan) 5. Floor Plans?(new construction only): Yes�° F 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: Focls by 1k `(Address of septic system) (Engineer) r Relative to the application of M r;4�v_{J (Installer's name) And dated 1V (Uriglnal date) Dated �[( o ay' te) With revisions dated lIct 1 (Last reviled date) 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 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: healthdept @townofnortliandover.com) 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 tlian 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 stem 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 solel_responsible for the installation of the system as per the approved 121ans No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: q (Today's Date) /l/(CL*444 et,ttAc.11 (Name—Print) ne— Signe