HomeMy WebLinkAboutHealth Permit # 7/18/2013 Commonwealth of Massachusetts Map-Block-Lot
• 104.A0085
°
BOARD OF HEALTH -----------------------
Permit No
North Andover BHP-2013-0816
FEE
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
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to(Repair)an Individual Sewage Disposal System.'b CPA I�,;�
at No 72 SAW MILL ROAD
S
as shown on the application for Disposal Works Construction Permit No. BHP-2013 081 i Dated
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Issued On:Jul-18-2013 BOARD OF HEALTH
Agp�l:ication tic i I t "w.. r„7
TODAY'S DATE
60 NORTH ANDOVER,��O18�45 Construction r it
125.0° omp neat
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on
to the _ 7 *
computer,use ❑ Repa�lr or replace an existing an-site sewage disposal system
only the tab key ETf epair or replace an existing system component What. � ��'� �
to move your
cursor-do not
use the return A. Facility Information
w v
key. .,.
- ---- —
Address or Lot# 4 _��
('J L 8
2.- °fl(FE OF SEPTIC,SY 1°EIVI*: K)t N OF IKkwOR ✓wl i r;�✓t�'
HEALTH h ' l t. l➢ [] Pump ❑ ravity(choose one) ,
***If pump sy am, attach copy of electrical permit to application*** �
Conventional System (pipe and stone system)
➢ ❑ Infiltrator or Bio'diffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
➢ ❑ Pressure Distribution S.A.S. (No D-Box)
> ❑ Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No r°
If yes, does plan specify make and model of filter? YES =(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make? What is the Model?
2. Owner Information
Name w
Address(if different from above)
City/Town Code
State Zip
-
Telephone Number
3. installer Information
Name Name of C mpany��1ii�LA BGAD
�f/ �-+
Address
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. designer Information
Name Name of Company
Address
City/Town ---- ------_ -- -State - — Zip Code ---
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
, Iii ti n r tip 1 t N �
TODAY`S DATE
Construction Permit — TOWN OF
NORTH ANDOVER MA 01845 $250.00®Full Repair
$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
North Andover. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approved.
w
Name ,,� Date-
Application Approve �y: (Board of Health Representative)
Name Da a
-- te
Application Disapprovedj)r the following reasons:
For Office Use Only:
L Fee Attached? Yes No
2. Project Manager Obligation Form Attached? Yes No
3. Pcunp S sy tem? If so,Attach copy ofElectrical Permit Yes No
4. Reviewed approvalletter, allpapenvork received? Yes No
Missing:•
5. Foundation As-B'ui'lt?(new construction only): Yes No
(Same scale as approved plan)
6: Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEp'xIC-S.Y.STEM.'II�TSTAI.IaE PROFECT MA �'GEIviENT,OBLTG-TIONS
As the-North Andover.liceased installer for tlie-c6nttmcOQft f¢r.'the septic system,for.the prbpe ty at:
For plans by
(Address of septic system) (Engineer)
Relative to the.application of And dated
(in'staller's name) ngina a e .
Dated ° With revisions dated
o a r a e (Last revised date)
I understand the following oliligations 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 at�broved tilans and theermit'on site when any work is
Ecinglam
2. As the inst Uer;.Imiust.,c.o.for any and allinspe'ctions: If homeowner,contractor,.project mailAger, or any
other person not associated with my company schedules-an inspection and the system is not ready,then
item three'sh4b.e.applicable.
1' As•tli,,igsoher;I'atxi-req#ed to.have.the rtecessirywork-completed.prior"to the.applicable inspections as
itidicated below- Ltid& §tand that reque'stin spection,without comliletion of the items in accordance
with Title 5 and'th Bbard of pTeaitli Ii a ula ons•may result in:a$50 00.. e•beffiltlevied a�au�st me..and/or
1' s ectio tmlirss,there is a ietainin wall,which
',Botfom�f•B.ett Generally,tliis'is the.1ist. . )'ire p • n', , g
should-be dtti ie<iYrst: Tlie Installer iriust bequest a iiiSpectidt7 but sloes riot have to be present. .
b. final�o'n�tru tlon.I",.i2 tioti-EVneer mi�st'fjrs :clo'tlxeii~iixspecfion for elevations;ties,'etc.
As-bdilf of'ver'bal OK(or e-mol•to:healtlid t�,t��own_ofriorthandover.com):from the engineer must
be stibniitfed to'.xlie,Bo'axd-of Health,aftex:whii h:insta el r.ca3ls for,an insp'ectipn time. Installer must
bepresent for this.inspection, With•a ptipp..system;411•electrical•work;•must;be ready and able to
causd;gulp.t6-tdork ghd•alarm.to funotion..
c. Final Grad'-Titstaller must request inspection when ill grading'is complete: Installer*does not
Nave to be
-on.site.'
4. As-the installer,'I understand that only I'�ay perform the work*(other than:simple exeapation)and i atri required
to complete the-installation of the system identified in tli attached.appli"catioii for.installation:'.I fbith'er
.undersitand'•that Work doine'bv others .....cens�d•to'iris =rep�•ysfems•in North Andover can constitute
reasons for deiiial•cif tht'systern andlor�ievocation or suspension of•my lieense•to operate in.the T.own.of
North Andover siOficant fines Xo all lZerso'ns•iribolved are also'possible
5 As the.installer, I tiiaderstan' that'.I: uit#fie on-..site'during fhop.7.tinnance of the-following constYixction
steps:..
a: Determinatiorf that.theprop ' elevation of the adon has'been reached '
A Inspection of the'sand and stone-to be used
c. Final nspecdon by Board of i<Iealth staffor consultant,
d. Installation.•oftank D-Boxf pipes,stone, vent,pump chamber,retar'rung waUand other .
components.
6. 4s th2insfaller., i understand that I:am solejy respQ sn ible for the installation.of the.system as per the
pp gd;p p. No ins,*ructiQns by the homeowner gtneral contractor •or any other persons shall.absolve
me Qf-ihis obligation.
Undersigned Licensed 'c.In taller: o ' ��' �`°l�
C�' da -'.s Late):
c. .��'S -777777.
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