HomeMy WebLinkAboutHealth Permit # 11/5/2015 ,x t ►n . Commonwealth of Massachusetts Map-Block-Lot
BOARD OF HEALTH -_
Permit it
No
North Andover BHP-2015-0364
P.I. FEE
F.I. $250.00
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Jesse T. Warren
to(Construct)an Individual Sewage Disposal System. €
at No 540 BOXFORD STREET
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as shown on the application for Disposal Works Construction Permit No. B _201.5-036 Dated
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Printed On:Nov-05-2015 ALTH
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SIC tion for tic yst n1 ,° ._
I& ull TODAY'S ATE Onstruction Permit - T NORTH ANDOVER, MA 01845 Repair
$$125.00-Component
Important: Applicationjs Application hereby made fora permit to:
When filling out ETConstruct 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
Facility Information
use the return A. FaC .. - ..
key. t
Address - �• t t
s or Lot#
tab -- -- -
h rW
City/Town
rafurn 2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump [jj,°,6ravity(choose one) ��tS'"�� �, �,,....
***If pump system, attach copy of electrical permit to application*** k� `
➢ a^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)
➢ ❑ Pressure Dosed (D-Box Present) S.A.S.
➢ ❑ 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 DWC issuance)
What is the Make? What is the Model?
2. Owner Information
C_
Name
Address(if different from above)All — (lay
Z
City/Town State i �p e
y �" f � C
Email address Telephone N rnb
" (
p er
3. Installer Information
—� - c r– ,
Name Name of Company
— .,
Address
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City/Town State Zip Code --
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
A.)
_
Address .-_---____
--
------------ --
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 11 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(adra s,a of septic a y,tctz) For plans b y
(Engineer)
Relative to the application of
(]ns allel"S name) And dated
dare)
Dated t c gat
5r.:a' , e) With revisions date
A
d
(Last revised date)
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 pdor 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,l 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: Ixetlthdt i> vtre�r�i��«rEar<tncle��i�.r.twerr ) 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 (otherlban simple excavatiofa)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: (Today's Date)
( 'arne...- Print ( afnk"
. TMryy;Vl,, . Ili ti on for tip Disposlal System
Construction Permit — TOWN TODAY'S DATE
$ 250.00-Full Repair
NORTH ANDOVER, MA 01 $125.00- Component:
PAGE 2 OF 2
A. µ._ .
Facility Information continued....
5. Type of Building: 2fresidential 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
Compliance has been issued by
this Board of alth, the installed system is not approved.
North Andover.t understand that until a final Certificate of
Name Date
A c tr
p on Ipproved 8y: ( pa��l ofHealt Representative)
'
r
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N e — Date
Application Disapprov�d for the following reasons:
For Office Use Only:
1. Fee Attached? Yes `a No
r
Z. Project Manager Obligation Form Attached? Yes ,/ No
3. Pump S sY tem? If so,Attach copy of Electrical Permit Yes No V,
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No's
Handout.
4. Reviewed approval letter, all paperwork received? Yes No
Missing:
J Foundation AS-Built?(new construction only): Yes No
(Same scale as approved plan)
G Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2