HomeMy WebLinkAboutHealth Permit # 7/16/2004 ....e ............ .....
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Jul 13 04 12: 00p NORT1-1 (IN DOVER R "1196089542 p. 2
TOWN OF NORTH ANDOVER 04 ptUfiTF,
office()I'CONIMli1NITY DEVELOPMENT AND SERVICES
14EALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER,MASSACHUSETTS 01845 pSSACNIIS�
Susan Y.Sawyer,RRJ3S/RS 978.088.9540—phone
Public Health Director 978.08'8.9542—FAX
heal thdot totownofriorthandovec.com
www.towrioftioi-(hat)(I o\lci'.CollI
Apk�LICATI®Pd I'�1� I�ISP�SAL VV�ItI�S Cf�IVSIIZIICTI��J 1pEII T
DATE:
I,OCATICINd q�..,
LICENSED INSTALLER NAMIda
PLEASE PRINT
A
ELEPH0NE '
SIGI'�ATUII;L,°
CHECK ONE:
FULL SYSTEM REPAIR:
COMPONENT REPAIR(indicate what parts):
*NEW CONSTRUCTION:
*If NEW CONSTRUCTION,please attach the Foundation As-Built Plan,
X250°00 Fee Attached? Yes No .�. .
Project Manager Obligation From Attached? Yes '" _ No
Foundation As-Built? Yes No ""
Floor Plans? Yes No m
Approval of.Health Agent :,� ° ,�. Date._._ .z �
JU 1 13 04 12: 0010 t` O TH ANDOVER 970GO09542 p. 3
INSTALLER PROJECT MANAGEMENT OBLIGATION
r fo
he construction of the septic systern for the
✓ � � installer P,
As the North Andover license
property at (C., � ? ` relative to the application
µ...ms
_ 4,7q A-f dated () 7. t. for plans by e' ALL 1 acrd
dated r K, with revision,,dated l
I understand the Hollowing obligations for management of this project:
I. 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 mast have the approved plans and the permit on site
when any work is being done.
1 As the installer I must call for any and all inspections. If homeowner, contractor, project
manger,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 1 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 Tile 5 and the Board of Health Regulations may
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 clone
first, Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, tics, etc. As-built or
verbal OK from engineer must be submitted to Board of` Health, after which installer calls for
inspection time. Installer must be, present for this inspection, With pump system all electrical
work must lie 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,
4, As the installer I understand that only I may perform the work (other than simple excavation)
required 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 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.
Un ersinned Licensed S is Installer
.. ,... ... Date: M„
Dis o�al Works onstruction Permit#
Jul 13 04 12: 01P NORM H ANDOVER 9'706009542 p. 4
VA
t
TOWN OF NORTH ANDOVE R SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTUICATION
TX'h ndersigned hereby certify that the Sewage Disposal System( )constructed;
( repaired;
by `�-
located at /6 V i� .l ... I f� c l 1� c u. f C V,
was installed in conformance with the Iarth Wdv,,r Board of health approved plan,
Systea Design Permit plan dated , with a design flaw
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 15.00,Title 5 and local regulations,.and the final grading agrees substantially with
the approved plan. All woik 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
fnstaller�" - � '. .._, .�mw � . c':#: Date: � k
.Engineer: .Date:
0.