HomeMy WebLinkAboutHealth Permit # 6/3/2005 OCR
Commonwealth of Massachusetts Map-Block-Lot
0� o� 107D-0010-
Board of Health it -
Per mit No-----------
Per
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North Andover BHP-2005-0166
�i3S4ewu"�` FEE
$250.00
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Disposal Works Construction Permit
Permission is hereby granted ROBERT INNIS
to(Construct)an Individual Sewage Disposal System.
at No 240 GRAY STREET LOT 4
as shown on the application for Disposal Works Construction Permit No. BHP-2005-016 Dated June 03,2005
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Issued O--Jun-03- --- Board of Health
TOWN OF NORTH ANDOVER IkONTPI
Office of COMMUNITY DEVELOPMENTAND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
0
NORTH ANDOVER, MASSACHUSETT'S 01845
978.688.9540—Phone
Susan Y. Sawyer,REHS/RS 978.688.9542—FAX
Public Health Director heal didept(p tow n o fii orthan dover.com -e-mail
www.townofnoi-thaiidover.com-website
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:
LOCATION:
LICENSED INSTALLER NAME:
PLEASE PRINT
SIGNATURE:
....... TELEPHONE# 92 F 6
4 CHECK ONE:
FULL SYSTEM REPAIR: ($250)
COMPONENT REPAIR (indicate what parts): ($125)
* NEW CONSTRUCTION:
* If NE$'CONSTRUCTION, please attach the Foundation As-Built Plan.
$250.00 or$125 Fee Attached? Yes V No
Project Manager Obligation From Attached? Yes No
Foundation As-Built? Yes No
Floor Plans? Yes ....... No
Approval of Health Agent
Date:
INSTALLED PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
at � � ^��;,_� .��1_.
property ` relative to the application
of dated for plans by s "it, k ao, ,,,and
dated 13 o with revisions dated
I understand the following 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 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.
Undersigned Licensed Septic Installer
Date: 1"
Disposal Works Construction Permit#