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HomeMy WebLinkAboutHealth Permit # 10/27/2014 Commonwealth of Massachusetts Map-Block-Lot 106.A0146 ----------------------- BOARD OF HEALTH • Permit No North Andover BHP-2014-1278 P.I. FEE F.I. $125.00 DISPOSAL WORKS CONSTRUCTION IT Permission is hereby granted James Boraczek to(Repair)an Individual Sewage Disposal System. at No 41 CEDAR LANE as shown on the application for Disposal Works Construction Permit No. BHP-2014 7127 Dated _ October,27 2014 - - ------------------------------------------ Issued On: Oct-27-2014 BOARD OF HEALTH f `,� Application f0r fi Disposal y f `.... ti Construction Permit - TOWN TODAY' AT NORTH ANDOVER, MA r $'250 .�.�®.,FLsll Repair 01845 $ Important: Application is hereby made for a 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 epair or replace an existing system component®What? �✓ is cursor-do not use the return A. Facility Information key. �� Address or Lot# ----------- rah ---- --- - V. 2.® TYPE OF City/Town SEPTIC SYSTEM*: ❑ Pump ravity(choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biadiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.) S� ❑ Pressure Distribution S.A.S. (No D-Box) ❑ Pressure Dosed (D-Box Present)S.A.S. Y ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO =(installer must specify brand of filter before®WC issuance) What is the Make? [Y/liat is the Model. 2. Owner Information ---Y 71 - ------------ Name Q Address(if f/Ydifferent from above)elv -!/ City/Town State Zip Code �o 11A Telephone Number 3. Installer Information cxd�t . �'r°)��'2 �L!� Srr� yc ✓ " ��' / w -Al Name Name of Comp Z/ Addre s . TM 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 Application for Se tic is n t o • � '" Construction Permit TODAY'S DATE NORTH ANDOVER MA. $ 250.00- Full Repair®�X45 $125.00 - Component PAGE 2 F A. Facility Information continued.... 5. jype 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. Name Date Applica n Approved EW. (Board of Health Representative) a - N e Date ---- - -- Ap ication Disapp oved for the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager•Obligation Fortn Attached? Yes No 3. Pump Sys tern? If so,Attach copy of Elecuical Pertnit Yes No 4. Reviei-ved approval letter, all papeiworlc receiveda Yes No Missing 5. Foundation As-Built?(crew 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"T"IC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATICINS As the North Andover licensed installer for die construction for the septic system for the property at: (ec"111CY 6V (Wdre , (4"Sep6c slysteln) For plaits by Relative to the application of C/m-eS ✓yjC,.Z.e (11stffler"" name) And dated t rtgin d etau) IJated �//y �� '�a �:a�r� With revisions dated (Last rcg isel d'me;) 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 riot to performing any work on a site. I must have the approved ved 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 requited 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 compan�L 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:�;?c_t1ih�:1;° ��_f�ld>,9,t�r�v9laf�rlatl tlt�aa�;lai�,��.� t q�t`[�) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection tune. 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 alarin 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 tbaH simple excanition)and I am required to complete the installation of the system identified in die 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 die 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•oved plans. No instructions by the honzeowner,general contractor, or any other:persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: ; A/ a itne 1'':¢,-t77) 7 Nattrxt° .. _ tIec.