HomeMy WebLinkAboutHealth Permit # 10/16/2006 u�.RH Commonwealth of Massachusetts Map-Block-Lot
10TD-0016-
Board of Health Permit No
x BHP-2006-0695
North Andover
m�
FEE
0 $250.00
Disposal Works Construction Permit
Permission is hereby granted
to(Construct)an Individual Sewage Disposal System.
at No 168 GRAY STREET
as shown on the application for Disposal Works Construction Pen-nit No. BHP-2006-0 Dated October 16,2006
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Issued On: Oct-16-2006 Board of H alth
�40H7N pplicatio 'or Septic Disposal yst( - i
I6�
b HO),Construction Permit ® TOWN OF TODAY'S DATE
r OR DOTER, A 01845 $ 250.00—Full Repair
ygss^CHU5� $125.00 - Component
Important: Applicatioi34s hereby made fora permit to:
When filling out Construct a new on-site sewage disposal system*
forms on the
computer, use ❑ Repair 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 '
6 11 Address or Lot#
en�ny_ City/Town
2.- *TYPE OF EPTIC SYSTEM*:
❑ Pump Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional 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(if differe t from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name _ Name of Company
Address ` IF
City/Town St at Zip Cott
Telephone Number(Cell Phone#if possible please)
4. Designer Information
N me Name of Company
0 Pox /6)/6,
Address
City/Town State Zip Code
9 (;1J- 15—
T leT ephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
�aM ° ti r Septic I t
^' pa%Construction Permit TODAY'S DATE
ANDOVER MA 01$45 250.00_ Full Repair
$125.00 - Component
SA
PAGE 2 OF 2
A.cwua
Facility Information continued....
s. Type of Building: HResidential Dwelling or❑Commercial
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
been i sued by this Board ofr�Hea th.
Name Date
Applic ion Approved r(Board of Health Representative)
ra
Date
�` Application Disapprove for the following reasons:
For Office Use Only,
Z Fee Attached? Yes�_. _....M No
L-
2. Project Manager Ohligation Form Attached? Yes No
3. Pump S s� ? If so,Attach copy ofElectrical Permit Yes No
4. Foundation As-Built?(new construction ronly): yes("-
es("- ,,.. No
(Same scale as approvedplan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit-Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATION
As the North Andover licensed installer for the constr tction fpr the septic system for the property at:
r
(,Wdress of septic systenx) For plans by AIx
Relative to the application of ^�°�' �" �"�l ���� �^ Vol'/
(Installer's name) end dated C
Dated
o day's date With revisions dated _
(Last revised dap(e)
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 ip•ior 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 company.
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 OIL (or e-mail to: l,caltl ck.l t<)tr>� ras>f rr:>rtlt r 7(Lo c_rr;coii ) 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 sir71ple exwtw ion)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
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: (L'odayrs I)at:e:)
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