HomeMy WebLinkAboutHealth Permit # 11/26/2003 APPLICATION FOR DISPOSAL, WORKS CONSTRUCTION PERMIT
DATE: CURRENT INSTALLER'S LICENSE#
LOCATION: (I (/ 101 �?(ffiAj
LICENSED INSTALLER: 'v" vi ('(j r Q(j t (,%J'J
SIGNATURE TELEPHONE#
CHECK ONE:
REPAIR, '/ NEW CONSTRUCTION:--------------
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
>,$ .00 Fee Attached? Yes No
Foundation As
Floor plans on
Approval Date:
J
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
ION
The undersigned hereby certify that the Sewage Disposal System ( )'constructed;
( ) repaired;
by
located at_L1,tj A NJ d�-t 1 C �7� : ,,.._.._
was installed in conformance with the.North Andover Board of Health approved plan,
System Design Permit# ,plan dated , with a design flow
of gallons per day. The materials used were in conformance with those specified
on the approved plan; the system was installed in accordance with the provisions of 310
CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with
the approved plan. All work is accurately represented on the As-built which has been
submitted to the Board of Health.
Bed inspection date:
Engineer Representative
Final inspection date:
Engineer Representative
Installer: C .. ..._.._ _r__
_ Lrc. Date:
Engineer: Date:
;; if �::
INSTALLER PROJECT MANAGLIVI. r OBLIGATIONS
As the North.Andover licensed installer for the construction of the septic system for the
property at 1(' % 9 ,t 'w� .�_..4 at 4;...r. relative to the application
of_ v ,� ,rA��x
dated 1 � �.��1 o for plans by 1`� °�", � G and
dated ��� with revisions dated
I understand the following obligations for management of this project:
1. As the installer lain obligated to call for any and all inspections. If homeowner, contracto
project manger, or any other person not associated with my company schedules an inspectio
and the system is not ready then item two shall be applicable.
2. As the installer I am required to have the necessary work completed prior to the applicabl
inspections as indicated below. I understand that requesting an inspection,, withou
completion of the items in accordance with Tile 5 and the Board of Health Regulations ma:
result in a$50.00 fine,being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be dons
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built of
verbal OK from engineer must be submitted to Board of Health, after which installer calls foy
inspection time. Installer must be present for this inspection. With 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. Does not have to be
on site.
3. As the installer I understand that persons or companies not associated with my company may
riot perform the work required by my company to complete the installation of the system
identified in the attached application for installation. I further understand that work 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 in the Town of North Andover plus
significant fines to all persons involved.
4. 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.
d) Installation of tank,, D-box, pipes, stone, vent, pump chamber, retaining wall and other
components.
5. 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.
Un rsigned Lic s d Septic Installer
Date:
Disposal Wor Construction Pern-it#