HomeMy WebLinkAboutHealth Permit # 4/3/2012 ® y Commonwealth of Massachusetts Map-Block-Lot
® 107.A0091
BOARD OF HEALTH
North Andover
CERTIFICATE
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-FULL SYSTEM)
by "_"Mike-Reilly"-------------------------------
-----------------------------------------------"-------------------------------------
Installer
at No 940 JOHNSON STREET
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-2012-054
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Printed On:Apr-03-2012 BOARD OF HEALTH
t �
lip ti rt r tip r I y stem
tr �tf f1 r it ® TODAY'S DATE
01845 $250.00—Fun Repair
$125.00 -Component
�mm
Important: Application is hereby made for a permit to:
When filling out —
forms on the ❑ Construct a new on-site sewage disposal system*
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. Facility Information RECEIVED
940 Johnston Street
------- -- ---- --- ---- ---
u Address or Lot#
— --- --
North Andover
ra'�sn City/Town TOWN OF NORTH ANDOVER
- —
Ir"IEA6,:"�"t"'�
2.-*,TYPE OF SEPTIC SYSTEM*:
ump ❑ Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
❑ C ventional System (pipe and stone system)
Znfiltrator 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
Dave Taylor
Name
12 Souhegon Dr.
Address(if different from above)
Nashua NH 03063
City/Town State Zip Code
603-315-3864
Telephone Number
3. Installer Information
Michael W. Reilly F. P. Reilly and Sons, Inc.
Name Name of Company
206 Andover Street,Suite 11
Address
Andover MA - 01810
City/Town State f,,"" Zip C de
978-475-1237, 78-375-4811
------------ ---- -
p r(Cell Phone#if ossi /e please)
Tele hone Numb , / ` 4"' "r"� V( j-'( f,
4. Designer Information .
Merrimack Engineering
Name Name of Company
66 Park Street
Address
Andover MA 01810
City/Town State Zip Code
978-475-3555
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
JUN-1-2004 10:55P FROM: TO:19784753102 P.1/1
Date......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
z .
tab
Thiscertifies that ............... ................................. .........................................
has permimion to perform ..........,r .............
wiring in the building of......... .................................................
at.........
( r......a.�.............. North An UO.V...... .M....
a..ss.
Fee.4re 11c.No.-;W, 7A r...... 9 ....
. . .
Check # hk7d id
—-- --------
ion for tip i l y t
w . on tructi n Permit - TOWN OF TODAY'S DATE
$250.00-Full Repair
� .
(JR T H ANDOVER ALA. 01845
,dug: $125,00-Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of gilding: ❑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 i stfed'by this Board of Health.
Name Date
r�!
sF
Applic icon Approved 13y6oard of Health Representative)
- - --------
N r�re � Date
o"'
'Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes 1 No
2. Project Manager Obligation Form Attached? Yes 4,111 No
3. Pump System? If so,Attach copy of Electrical Permit Yes L°' 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
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SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the aopo' t for system cproperty at:
�\ddzm,uFn«p6coyo,co�)
For plans L7
Relative mthe application of �
(luomDe,'s ouo`c) �—�--- /\odJ^teJ !
)rIg"IA date)
Dated
With revisions dated
pLuartcriscd( urc)
K understand the following obligations for management mf this project:
|. As the installer, Iucuobligated to obtain all permits and Board o[f{eult6 approved plans pdor to
performing any work on m site. I must have the approved 121ans and the permit on site when any work is �
being done,
2. As the installer, I must call for any and all inspections. If6cunuonozcz, contractor,project manager, orany �
other person not associated with my company schedules an inspection and the system is not ready, then �
item ih,uc shall be applicable.
3. z\o the installer, Tum required io6avedbouccossuryv/nrkcooxJotcdp6ortor6cupoBcublciuxpombonsua
indicated b
with Title 5 and the Board of Health Regulations 1-na-y result in a$50.00 fine bein.g levied against me and/o
my company.
u. Bottom of Bed—(}uzczoO" this is the first (I`) inspection unless there is uretaining wall,which
x600lJ be done first. 7'lic installer must request the 6oapcctimu but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
z\x-bnd1 of verbal ()K /or e-mail Lo: from the engineer uznst
be submitted to the Board oE Health,after which installer cxOu for an inspection brnc. IoatoDoz 000xt
be pzcycot for this inspection. With u pump ayotoco`all electrical work must be zcuJ, and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading ixcomplete. Installer does not
have to6uoo'xik.
4. As the installer,]understand that only Tmay perform the work (olbmtbmonzpk excaxwlion)and Iomrequired
to complete the installation of the system identified in the attached application for installation. I further �
understand that work done b)�others unlicensed to.install septic systerns in North Andover can constitute
reasons for denial of the North Andover, sigWficant fines to all persons involye. d are also possible.
' |
5. As the installer,Iunderstand that Ioustbe on-site during the performance of the following construction |
steps:
/z Determination that the proper elevation of the excavation 6uz been ro«xbxd.
b. 7m/»vxtiow of the sand and stone to be wsxa[
c. Final inspection bv Board »fHxu/t6 staff urconsultant.
d. Installation of tank, 77-8*x,pipes, stone, vent,pump xbambxr' retaining wall and ot6xr
components.
6. As the installer, I understand that I arn 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:
(!Name PfUlt) _77711c 771'T'ned)
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