HomeMy WebLinkAboutHealth Permit # 10/27/2008 Map-Block-Lot
1o7.0-0047
Commonwealth of Massachusetts permtNo
N��TM q of Health BHP 2008-0212
tia Board ----
4= North Andover FEE
$
~ -------------250-00
--------- 250.00
—
a
F.I. Construction Permit
'T
SSA osal W orks ---------------------------------------
mes Kelltte ----------- -
anted - ----- ----
--------------
permission is hereby gr Ja stem.
Disposal Sy
to(Construct)an Individual Sewage - -
--- October 27,20 _____
08
AN DRI BHp-2008 0212 Dated
atNo _99MARI_--
VE ---- -
hcationfor Disp
osalWorks Construction Permit No. ____ _-_----
on the app ___
as shown ------
- Board of Health
Issued on-:Oct-27-2008 -----
--_--------
Of pORT sAtiO Application for Septic Disposal System
TOpAYZ_DAT�_
Construction Permit - TOWN OF °
ORTH ANDOVER MA 01845 $i5o.00— Full Repai
+,.o•" a5 ! $125.00 -Component
9SSACHus -
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 epair 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
rab Address or Lot#
WV o'-d ,Q/3G�dUt�
r City/Town
2.- `TYPE OF EPTIC SYSTEM :
❑ Pump FGravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ C ventional 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
? 2
Telephone Number
3. Installer Information
Name Name of Company
1
Address
4 11W4
Cit� State Ji Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
A'. �� r
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
pORTH Application for Septic Disposal System Z
112/o�
O�it n ; qYO
sConstruction Permit — TOWN
OF TODAY'S DATE
ORTH ANDOVER, MA 01845 $ 250.00— Full Repair
$125.00 - Component
�SSACHuSE�
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: esidential Dwellin 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, and not to place the system in operation until a Certificate of Compliance has
bee sued by this Qoar of Health.
Na a Date
Applicatio Approved By-, Board of Health Representative)
Z
Name/ Date
`Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached. Yes- No
2. Project Manager Obligation Form Attached. Yes No
3. Pump System? If so,Attach copy of Electrical Permit Yes No i� J
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:
/ r
(Address oC septic, syston) For plans by / ��1✓
Relative to the application of ('7)/,7
(Installer's z7;sstrey)
And dated
(()ngjna1 date)
Dated 1 C'
c� a� s c atcM With revisions dated
(Last revised&ite,)
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 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 companL
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 OK (or e-mail to: 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 (other than silliple 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
h. Inspection of the sand and stone to he used
c. Final inspection by Board of Health staff or consultant.
d Installation oftanlc, 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: ("1`oday,'s Date.)
111, Print) , 1p',Iec: ..
rrJ� sor
Date. 14
of, T"14, TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . . .� . . . .��. . . . . .
has permission to perform . . . .N.r!!.•�.�- . . K � �". . . . . . • . • . . .
plumbing in the buildings of . . . A!. . . . . . . . . . .
at. . . . .D lt. . . . . . . ., North Andover, Mass.
C
Fee. Lic. No..Ct . . . . . . . .Q . . . . . . . .
PLUMBING INSPECTOR
Check #
7896