HomeMy WebLinkAboutHealth Permit # 10/2/2013 Commonwealth of Massachusetts 107.AOMap-Block-Lot
045
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BOARD OF HEALTH Permit No
North Andover -----------------BHP-2013-0917
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FEE
$250.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Bill Hall Inc. ----------------------------------------------------------------
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to(Construct)an Individual Sewage Disposal System.
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at No 858 JOHNSON STREET ------------ ----- - ------------------------
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as shown on the application for Disposal Works Construction Permit No. BHP-2013-091--- Dated---October-0-2,-2013
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Issued On: Oct-02-2013 BOARD OF HEALTH
t
ion for Se tic i l stem
T DAM'S DATE
n truction Permit — TOWN F
8
Y p�W"n
, 50A PulI,kt?air
` �l 0145
W Coimponent
Important: Application is hereby made fora permit to:
When filling out 29 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
Y y
0 Address or Lot#
m m City/Town
2.- *TYPE OF SEPTIC SYSTEM :
❑ Pump ❑ Gravity (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 /
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Company
I_I ) Q (A _
Address
l S'-(4
City/Town State rv/ !y' / y p Zip pCode
Telephone Number(Cell Phone#if possible please)
4. Designer Information
w ,
Name Name of Company
IV\IL
Address
City/Town State Zip Code
"2K -5 s i 0
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Oce '
� licatioln for tip i I � t
n truction Permit — TOWN TODAY'S DATE
`�' 01$4 $ 250.00-Full Repair
y "` $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: gResidential 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.
Name Date
Application Approved_,y_4 and of Health Representative)
� ry
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee AttachedP Yes No
2. Project Manager Obligation Farm Attaclied? Yes No
3. Pump System? If so,Attach copy of Electrical Permit Yes Na
4. Foundation As-Built?(new construction ronly): Yes Na
(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:
�.. s
t
(:Wr.dre's", of ,a irdia sl .,rent) F+'or plans by �7("� S`"tQ ll_�SC')r -4--
(ll ard.d�net:�')
Relative to the application of
vratIIe) And dated
Dated 10._2
�—�Tr:,c,m` ea
r ar— e) With revisions dated
(q'a t 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 piLor to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
Z 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 (Vs 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 l.c ilA9;l_a:lt p9Yw)q:�a aka>, n�+ ��lr,iFarlr �� , ��� t,) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection tune. 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 siliple excamlion)and I aim 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: �'� / � ("Toda ly"s Dal()
`.l."a;{.�!�,.. ItI l� I{�.�.d)