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Home My WebLink AboutHealth Permit # 8/27/2008 NUMBER FEE 2 i� THE COMMONWEALTH OF MASSACHUSETTS �a� G a� This is to Certify that ......... AME RESS IS HEREBY A LICEN For .. �.-.� .. ....%;k.............................. .......................................................----•----........----•---------...------.........-•--------------•-. -•-•--•---•-•-•--------•-----•-••-•-•-•-----•-- ........•--•-•••---•.....................••••••---•---------••.............-----•.•----.•••------•-•------•......-•-•----_..- •............•--••...............••--- •--•-•-•--•-----•-•--.....-•-•-•......................••-...•-••-----------•----- .....................................................................---------•--•---•• This license is ant d in conformity with the Statutes and ordinances relating thereto, and expires............ .O -------------------------.-unless sooner suspended or revoked. ............... ...................................•------------------- ---------------------- ...�7z- -2.-116- ----------- a97-— -------*---------------------------......_.....••-------.............................................. ..... FORM 488 H&W HOBBSB WARREN iM ot"aa,-w Applica ion for ti i I y t �� YY�au 4°etia TODAY'S DATE Construction r it , �'Ma ll $ 250.00— Full Repair ��^•At.. 3 $125.00 -Component SACHUg� Important: Application is hereby made for a permit 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 p p g y P to move your Re air or replace an existing system component—What? cursor-do not use the return Q. Facility nformation _.....,_ .-e.-A key. y rs� Address or Lot# ._..... -- --—-- ---- t� icnsn City/Town e� ... w,w^_ a,� .. 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) , ***If pump system, attach copy of electrical permit to applicati n** � ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiff user(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 Address(if different from above) City/Town State Zip Code p,, €y a. Telephone Number 3. Installer Information . ,. . Name Name of Company 0r Address City/Town State Zip Code Telephone Number(Cell Phone#if possible please) a. Designer Information ---- - -------------------- Name Name of Company Address — Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 N ORTH Application for Septic Disposal System OF�t�an .e q�0 �? a� °� TODAY'S DATE ° pConstruction Permit — TOWN OF ORTH ANDOVER MA 01845 $ 250.00-Full Repair �9SS�cNUS��y ' $125.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Buildin esR idential Dwelling or Commercial Yp q ® 9 ❑ 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, an not to place the system in operation until a Certificate of Compliance has been issued bylthiX Board of Health. Name Date Applved By: (B rd of Health Representative) NamDate App for/"Io lw ing reasons: For Office Use Only: 1. Fee Attached.? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Svstem? If so,Attach copv ofElectrical 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: ddre f < �c y stc.r��} For plans by w� i Relative to the application of Ins 11c s n e pp And dated tn<a c N,1`c^ Dated ..„_ ,eve , oa F,�N,s dale) With revisions dated (l.,ast rc.vir:a°d (la1°c:.) 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 i•ior 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 OIL (or e-mail to: beal,t.1,z tgpj. 'tQyrr t fnortl,�andcay c(.�I1?,) 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 (oll)er than 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 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 the of this obligation. Undersigned Licensed Septic Installer: (I°odaN's 17,oe) b ..eld� ” p aine -- Tint) ,a b1e — Signed) TOWN Off'NORTH AN DOVER �� DE ,4 � tf� 61'COMMUNIT`i' DEVELOPMENT AND SERVICES j � KK E L1L llJl. DEPARTMENT 1600 OSGOOD STREET; Building 2-36 ° NORTH ANDOVER,MASSACHUSETTS 01.845 VSA a1' "'sa � 5'u�'�rt Susan V. Sawyer,RFHS/RS 978.688.9540—Phone Public Health Director 978.688.8476 FAX ONSITE WASTEWATER SYSTEM N T TI nl NOTE LOCATION INFORMATION ADDRESS: MAP: LOT: INSTALLER DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS � TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed Ha10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation—Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVER o�"n"r Office of COMMUNITY DEVELOPMENT AND SERVICES 0� 4, HEALTH DEPARTMENT � �w 1600 OSGOOD STREET;Building 2-36 NORTH ANDOVER,MASSACHUSETTS 01 845 CH C"US�� Susan Y. Sawyer,REHS/RS 978.688.9540--Phone Public Health Director 978.688.8476—FAX D®SOX ❑ Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 '/2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6