HomeMy WebLinkAboutHealth Permit # 3/31/2014 Map-Block-Lot
yt�r, q, Commonwealth of Massachusetts
--------------BOARD OF HEALTH PermltNo
BHP-2014-0489
North Andover ----------------------
FEE
$250.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Matthew Manning-------------------------------------------------------------------------------
to(Construct)an Individual Sewage Disposal System.
at No 42 Stanton Way - ------- --------- - --I--- -----
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as shown on the application for Disposal Works Construction Permit No. BHP-2014-048 Dated I I --_--
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Printed On:Mar-31-2014 -------------------- -------- BOARD O HEALTH
APOIIcation for Se tic Dis osal S to m _ '
ODAY
" T ' DATE
-Construction Permit TOWN OF
p $250.00—Full Repair MA ORTH 01845 $ Component
� 125A0 -
Important: A licatio °is hereby made fora ermit to:
When filling out Construct a new on-site sewage disposal system*
forms on the
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 A. Facility Information
key. ( _
r� Address or Lot#
ream City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
❑ Pump 176ravity (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 tiAR 3 1 '0 1
M. e � .� ~ _
Name
L7q C )tC !
Address(if different from' bove)
A)u: t-. _AA 0
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Company
Address
f-c , � 'A _ A M f)
City/Town Sta e Zip Code
T phone f4umber(Cell Phone#if possible please)
4. Designer Information
p ( „ .
.l 1 _�.. ". - ti •�..°a R"1„!""0� " ''W.'-4� "" A—,4` �� 5 C�-
Name Name of Company
Address
City/Town State Zip Code
� ',)'),3 - o�
-Teleph'bne Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
lic tin for tic i I y t —
.
'0 TODAY'S DATE
sConstruction Permit — TOWN
$ 250.00-Full Repair
1 $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building:CIResidential 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.
-,j3 —-IM
N me Date
Application Approved By: (Board of Health Representative)
Name Date —
Application Disapproved for the following reasons:
For Office U§q Only:
1. Fee Attached.? Yes LZ No
2. Project Manages•Obligation Form Attached? Yes No
3. Pump 5 sy tens? If so,Attach coQE of Electrical Permit Yes No
4. Foundation As-Built?(new construction ronly): Yest� ' No
(Sane scale as appf o ve d plan)
5. Floor Plans?(new construction only). Yep' 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:
j 6)
(Address o septtr,sysuc°tn) For plans by V �A 6. n
Relative to the application of A a-kk�\'e'z,1 /
(Installer's came) And dated
s-t�;;aaat c tte�
Dated Li
o ay s date) With revisions dated 6 A
(l„tst revised 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 pEor to
performing any work on a site. I trust 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 OIL. (or e-mail to: ,l,< �lt��icicl�t(cx>o�c�wia�,b,f,r�i<»st,�,lwtnc#�r�_�.:a�t�_�,rea) 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 that simple excauitiorr)and I air 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: l �Gl d i� (Today's y's 1.)ate';)
(Nark ...... Print (� _ ( �c _--sigticd