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Commonweal'; of Massachusetts ,
Application for Septic Disposal System TODAY'S DATE
°Construction Permit — TOWN OF $ 250.00- Full Repair
NORTH ANDOVER MA 01845 Fee (0 -Component
Fee CIRCLE ONE
Form 1A PLEASE)
A. Facility Information
Important: Application is hereby made for a permit to:
When filling
out forms on
the [Construct a new on-site sewage disposal system
computer,
use only the
tab key to ❑ Repair or replace an existing on-site sewage disposal system
move your
cursor-do ❑ Repair or replace an existing system component
not use the
return key. 1. Location of Facility
VQ - T
Address or Lot#
City/Town State Zip Code
2. Owner Information
M AM A- _S 1 l ill T-(
�z����' -
Name _
Address(if different from above _
City/Town State Zip Code
Telephone Number
3. Installer Information
Name _ Name of Company
'I i ran s C_
Address ii )
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Npme Name of Company
Address
(16) - V-�-( v U-�Yom- I/In ✓�" `�S
City/Town State Zip Code
Telephone Number(Best#to Reach)
*****TURN OVER FOR PAGE "2" PLEASE*****
Application for Disposal System Construction Permit•Page 1 of 2
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INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
C". /I
property at I relative to the application
�n5' X
of l iuc_- r h dated /'1 6 for plans by and
dated qllJLOq with revisions dated bS
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
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 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 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 done
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 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 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.
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.
Unders' ned Li ensed Septic Installer
I �
Date:
Disposal Works Construction Permit#