HomeMy WebLinkAboutHealth Permit # 6/29/2012 4
• �y LEn,, ' , Commonwealth of Massachusetts Map-Block-Lot
• 107.00053
BOARD OF HEALTH Penn it No
North Andover BHP-2012-0679
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P.I.
FEE
F.I. $250.00
DISPOSAL RIB ONST UC T'ION PERMIT
Permission is hereby granted Todd_13ateson
to(Repair)an Individual Sewage Disposal System. LDated at No 130 MARIAN DRIVE
as shown on the application for Disposal Works Construction Permit No. BHP-2012-067 29,2012
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Issued On: Jun-29-2012 BOARD OF HEALTH
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Construction Permit $„ Q��4 250.U0,�pull Repair
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$125 Op Component
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Important A lication ishereb made fora permit to:
When fining out ® Construct a new on-site sewage disposal system*
forms on the p Y J U NI
lu
computer,use epalr or replace an existing on-site sewage disposal s stn*
only the tab key �E7r GtiEn �A��
® � (r
to move your Repair or replace an existing system component—What?
P ,
cursor-do not
use the return A. Facility Information
key.
Address or Lot#
City/Town
p p tta�1C: ; py -@
®Pum ravlty(choose one
*e* .
!f m w: ysteen iectrical permit to application***
El Conventional System(pipe and stone system)
Ell-nfiltrator or Blodiffuser('ravel-!Mess) (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 own state a Zip Code
elr�
Telephone Number
3. Installer Information
M A,
BAD =
N�,NTERP[Jl c,,,INC.
Name Marne.of CompanyMOVA
MA 01 al
Address �
- e,vk,4 t-i
City/Town State' Zip Code
Telephone Number(Cell Phone#if posslble please)
4. Designer Information
Name Name of Company
�° .
Address
Zip Code
City/Town state
Telephone Number(Best#to Reach)
Applicatlor,for Disposal Systerh Construction Permit•Page 1 of 2
• • • •
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� �``,o .°,• o
� A tl TODAY'S DATE
n t ct� r it
e
ORTH DO C� $.250.00"Full Repair
$125.00-Component
ACHU`'�'
PAGE 2 OF
A. F cility.lnformation continued....
5. Type of Building: esidential Dwelling or OCommercial
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
Namew,..,b,.,
. date
Application A,'proved y: (Board of Health Representative)
f r" p
drr
a
Names' Date
Application Disapprove A'for the following reasons;
For Clffice Use only:
1 Fee Attached Yes t.,,..,.°'�x No
2. PtojectMapageJr Ohligation Form Attached. Yes`®` No
3.: PuMj2 S sy teem? If so)Attach copy ofElea cal Pennr't' NQ
4. Found adopAS-Built.?'(new construction ron(y): I'eS �� No
(Same scale as approved plan)
9. Floot Plans?(new construction only). Yes` No
Aop!1cat16n`for Disposal Systemloonstructiod Permit*Page 2 of 2
SEP'T'IC SYSTEM.INSTAL,LEIt PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system-for the property at:
' `fit" ��
For plans by
(Address of septic system) (Engineer)
Relative to the.a lication of f.�3tsJ'�
pp And dated / "7 �--
(In'staller's name) ngina 'ate).
Dated 4 �'�...- With revisions dated
—( o a s ate (Last 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 prior to
.performing any'work on a site. I must have the a roved:,lans and the permit'on site when any work is
being done•
2. As the installer,.I.must'call for any and all:inspations: 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.
1 As-the installer;1, -required to have the necessary.work completed prior to the applicable inspections as
indicated below: I:tineler`stand that re uekin 'an ins,ection without com letion:of the items in,accordance
with Title 5 and the Boatel of pTealtli Rggulations n resultin a$50 OO fine beinir levied against me.arid/or
rnv, com--'an • .. .:
a,. Bo'tfom of Bed=Generally,this-is th etaining wall,which
should be done first. The_installer 6.1st request-lie inspection but aloes not have to be present. .
b. Final Construetori.Inspectioti—Engineer-mnst first.do their..insjection for elevations,ties, etc.
As-built of OK(or e-mail to: heattl dept(u�townofnorthandover.com)from the engineer must
be stibniitted'to.the Board-ofHealth,after:which:installer.can for;an inspection time. Installer must
be present for this.inspection, 1ith a pump system;all electrical w4 ik;,must be ready and able to
cause putrip to work arid:alarm�.to furictton.. °: ..
c. Final Glade—Installer must request inspection then grading— 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 excavation)and I atn required
to complete the-installation of the system identified in.th attached application:for.installation::I farther
understand:that work done by others uriliceiised'to-install septic s� ys tems in North Andover can constitute
reasons for denial-of the system and/oirevocation'or suspension of.my licenseao operate in.the Town.of
North Andover significant fines to all persons-involved are also possible.
5.. .As the'.installer, I understand thatJ must'be on site during the performance.of the following construction.
steps,
a. Detenmivation-that.the proper elevattov of the excavation has been reached
A Inspection of the sand and stogie to be used.
c. Final inspection,by Board ofHedth staffor consultant.
d. Installation,of tank,D-Box;pipes,stone, vent,primp chamber,retaining wall and other
components.
6. As the installer, I understand that I am solel responsible for the installation.of the system as per the
,ap proved-Wans No instructions by thehomeowrier,general.contractor 'or any.other persons shall-absolve
me of this obligation.
Undersigned Ilceased Septic.Installer: day'a Date) 4 _J —i
gtne:— _gait y1� m6 t1 +}X..r
MP
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