HomeMy WebLinkAboutHealth Permit # 3/17/2014 Map-Block-Lot
• �t�r�.�.��,4' � Commonwealth of Massachusetts Ma
106.D0070
BOARD OF HEALTH Permit No
North Andover BHP-2014--- --
FEE
$125.00
DISPOSAL WORKS CONSTRUCTION IT"
Permission is hereby granted Robert-T.--Amor
to(Repair)an Individual Sewage Disposal System.
at No 72 WINDSORLANE----------I)-—-&)X-------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2014-045 Dated March 17,2014
-------- --------------------------- ---------------------------
Issued On:Mar-17-2014 BOARD OF HEALTH
44 lictin for Septic Dis l S stem
ra , ,ro
o Construction Permit F T(JDAY'S DATE
� �zo. Full Repair I , � �o
Component
Important: Application is hereby made for a permit to:
When tilling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use ❑ epair or replace an existing on-site sewage disposal syste *
only the tab key
to move your Repair or replace an existing system component—What?
cursor-do not
use the return
key. �A. Fac( �
Hit Information
rah Address or of#
n Ciwn
rcrcr
2.-*TYPE OF SEPTIC SYSTEM*:
❑ Pump rpsystem,ravity(choose one)
***If p 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. Qw-n-er-Informatiow
Name �
A d s if different from above)
City/Town State Zip Code
----- --- -------
Telephone Number
3. Installer Information
R 0 �r/ a
_ f �I ",. -�,..✓"`
i , - N me of Co p y
Ad res ,
City/Tow State Zip Co e
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
Application for Septi c Disposal t m _I
C.b Cy roAwR
" TODAY'S bATE
can ruction r it — TOWN OF
� ra `T' A 0145 $ 250.00®Full Repair
.wry o- c ° $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Tvpe of 13ulldlrl Residential Dwelling or FICommercial
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
Applicatj�n Approved Dy: (Board of Health Representative) f
w..
Name' ". Date
Application D,Approved for the following reasons:
For Office Use Only:
1. Fee Attaclied? Yek,,- ° No
2. Pfo'ect Mana er Obligation Form Attaclied? Yes No
F--
3. Pram S m Attach copy of Electrical Perm
,p Sys .� If so, it `-°Yes. Na
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