HomeMy WebLinkAboutHealth Permit # 9/30/2008 Map-Block-Lot
Commonwealth of Massachusetts
r °roc 107.A-0219-
Q
lift n Board of Health Permit No
j North Andover BHP-Zoos-o2o2
P.I. ---------
FEE
F.I. $250.00
Disposal Works Construction Permit
Permission is hereby granted James Kellett
to(Re air~ an Individual Sewage D p a System.
a o 45 CRICKET LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2008-0202 Dated September 30,2008
Issued On: Sep-30-2008
------ ---------------------------------------------
-- - ------------------------------------------------- Board o f Health
t
N ORTH
° Application for Septic Disposal System ,
�1*l!P
TO AY,s ATE
pConstruction Permit ® TOWN OF
*t° r ORTH ANDOVER, MA 01845 $ 250.00—Full Repair
CHUg
��� $125.00 -Component
9SSAE�
Important: Application is herebv made fora permit to:
When filling out ❑ C struct 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
key. y o /
rah Address or Lot#
cle
Mme, City/Town
2, *TYPE OF SEPTIC SYSTEM':
❑ Pump Ri3ravity(choose one)
***If punipp system, attach copy of electrical permit to application***
VnVentional System (pipe and stone system)
iltrator 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 different from above)
City/Town State Zip Code
Telephone Number
s. Installer Information
f�) [ / Name of Company
)()
Address
CityfTown State Zip Code
1J-/ . ! )- --�/1/ 6
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name I Name of Company
K00 0S qtr-
Address
A-1, IIJA
City/Town State Zip Code
U
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
Application for S tic i I
TODAY'S DATE
w
Construction Permit - TOWN OF
^" ` " '4 $ 250.00-Full Repair ORTH�9s5ncwus ANDOVER, $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: Residential 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
No , ndover, and no to play a the system in operation until a Certificate of Compliance has
bee sued by this ard,'of alth.
Date
Applicati ,r Approved By-,f1doard of Health Representative)
Name
Application Disapproved for the following reasons:
a_ . a. , ... _...
For Office Use Only:
1. Fee Attacheda Yes No
2 Pro 1 ect Mama g er Obligation Farm Attached?
Yew No
3 Pump,system a If so,Attach copy ofElectrrcal Permit Yes No
4. Foundation As-Built. (new construction ronly): Yes 'w No
(game scale as approved plan)
5 Floor Plans?(new construction only): Yes No
i
Application for Disposal System Construction Permit•Page 2 of 2
SEP''I"'IC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATION
As the North Andover licensed installer for the construction for the septic system for the property at:
riC' (C4, 1 wt
(Address of septic s}atc°m) For plans by
aAgr.neer)
Relative to the application of� t
(l°
nnsralk'x's 11,411,1e) And dated ��� , � � .,
�tl��i��ta (late
Dated (� Q
o ay;,date) With revisions dated
(1.mst revised dale.)
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 Rrior 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 the 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 OK (or e-mail to: heal�thdc pt a)towt ofriorthamd�)verxoni) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection titne. 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 (otber than simple excavation)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.
„ a (J
Undersigned Licensed Septic Installer: �� ., _ �_ (foday s Date) �
P
aid e-... Print) �€pT9- .. Signed)
Date. Gj. .y .
TOWN OF NORTH ANDOVER
° A PERMIT FOR PLUMBING
1SSACHUS� ! i
This certifies that . .h • • • I��• • •
has permission to perform . . . . ..P.vi• • • • • • •
plumbing in the buildings of . . . J.�. . . . . . . . . . . . . . . . . . . . . . •
c(z .. . . . . . . . . . . .. North Andover, Mass.
r-
Fee . . . . .Lic. No..�t/. . . . . . . .
PLUMBING INSP TO
Check #
7857
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