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Home My WebLink AboutHealth Permit # 9/5/2014 a06µOftT}{ pplication for Spgfic Disposal Sy§tem 6 /�o /y t+tto;O��O � TO Construction Permit — T DAY'S DATE "�. ...... T NDOVER, A 0184'5 $250.00—l=ull Repair �SSACH'is $125.00 -Component Important: ApplicatioD.Is hereby made fora permit to: When filling out Construct a new on-site sewage disposal system* 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 use the return key. A. Facilit y Information rQ Address or Lot# xio C -�� r C revn 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 Name 1671 ()_<>C,Q0A ,S. Address(if different fro bove) /in" %A /1 :j Cj 0V'?r mA 0 1 L1 City/Town State Zip Code Telephone Number 3. Installer`Information i q _ i Name ;;// ry Name of Company io � C kr� a+s Address 14ci-ne Sty City/Town St , Zi Code is T ho e Number(Cell Phone#if possible please) 4. Designer Information Niame Name of Company Address LA 3C City/Town State Zip Code (q--7q) 373 - 0:? tG Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 ao@,0_ raft p0icaten for ate v I y t .. * L ti Constructio i Permit ® TOWN TODAY S DATE ORTH ANDOVER MA 01845 $ 250.00—Full Repair � SAcHUSw $125.00 -Component PAGE 2 OF 2 A. Facility information continued 5. lype,,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. r Date pplicati n Approved /,( oard of Health Representative) Na Date / pp pprov forth ,��A lication Gib, e following reasons: For Office Use QnIW 1. Fee Attached,? Yes No 2. Project Manager Obligation Form Attached.? Yes No 3. Pump System? If so,Attach copy ofElectrical Permit Yes No 4. Foundation As-Buili?(nevi construction ronly): Yes No Game 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: (Address of septic system) For plans by 1-'k1 k C yl ts� C1 i (Engineer) Relative to the application of 114 Ll,�t��L j M e,a ni n� ZQ021(Installer's name) And dated ( )ri na ate) Dated �/0�/( //;�61100 With� With revisions dated Ll (Today ss date) r wised 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: healthdeptctownofnortliandover.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 than simple excaUation)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: 1-3 l (Today's Date) 1146L44 4Q M&a nr (Name—Print) (Np� e—Signed) N C6 M EASEMENT � A3. � I s I LOT 16-1 EXISTING FND. EL.=117.0' \ s LOT 16-2 \ X36 CV co 185.9' STANTON WAY N OF n'iq ss9 Z MICHAEL O J. N SERGI m L No.33191 q,y � I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTR FOUNDATION AS-BUILT (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER UCTED. RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, ORDERS OF CONDITIONS,ETC.)THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED AVE,EXCEPT WITH THE WRITTEN PERMISSION OF CLIENT: GREEN & COMPANY g ERGI INC.FURT ERMORETHS DRAWING IS THE COPYRIGHTEDN THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT PROPERTY OF CHRISTIANSEN&SERGI INC.AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRISTIANSEN&SERGI TAKES LOCATION: NORTH ANDOVER,MA. NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFORMATION CONTAINED HEREON. DATE:6/25/14 SCALE: 1"=100' PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI, INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGR.COM TEL, 978-373-0310 FAX.978-372-3960 DWG.NO.: 12007.001.012 Map-Block-Lot .- Commonwealth of Massachusetts Erg permit No BOARD OF HEALTH gHP_2014 oss4 North Andover FEE $250.00 ------------ F.I. ISP®SAh WORKS CONSTRUCTION PERMIT permission is hereby gr anted --------- - - -- --- ---- ------ - - -, g e Disposal System. p to(Construct)an Individual Sewa 1 u . at No 35 STANTON WAY--------------------------------- Se-tember05 2014 ----------------- as shown on the application for Disposal Works Construction Permit No. BLIP-2014-069__ Dated _p__________ _�------- - --------- BOARD OF HEALTH Issued On: Sep-OS-201----------------------------------------- --