HomeMy WebLinkAboutHealth Permit # 7/13/2015 Commonwealth of Massachusetts Map-Block-Lot
038.00162
BOARD OF HEALTH -Permit-No
North Andover -BHP-2015-0304
FEE
$125.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted -Todd-B-at-es-on----------------------I——--------------------- --------------------------------------
to(Repair)an Individual Sewage Disposal System.
at No 20 ENGLISH CIRCLE ---------btoi ------------------------
--------------------_------------- ---------------------------- ---------
as shown on the application for Disposal Works Construction Permit No. 13HP.-2_0_1_5_-_030__ Dated....July_l_3,_2_0_1_5_.__,___.,_
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_J
Issued On: Jul-13-2015 '-'-BoARD'6F HEALTH
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Q0 — TQDAI"S DATE
Construction Permit
NORTH ANDO VER, MA 01845 250.00'—Full Repair
$125.00®Component
Important: Application is hereby made fora permit to:
When filling out ❑Construct a new on-site sewage disposal system*
farms to the n —What?computer,use ❑Repair or replace an existing on-site sewage disposer system''
only the tab key 1
to move your p g y p
cursor-do not , ,
e air or replace an existing system component t VY at, �' �t`� ��.�.
use the return A. Facility Information
key. /
Address or Lot#
Cityfrown
2.-*TYPE OF SEPTIC..SYSTEM*: ���d)Wtq,O�w r.i� rl,i M1)(,, EF
> ❑ Pump c avity(choose one) i" ^� h�HMI N.i,.
' *lf pump syst attach copy of electrical permit to application"`
➢ onventional 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.
p ❑ 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 141odet:�
2. Owner Information
Name
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Co pany
r"ON r�
Address �— D
�pp ANDOVER, MA U'1 t3 10
CitylTown State Zip Code _
Telephone Number
ber(Cell Phone#if possible please)
4:. Desi ner Inforrrtatio
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
gdniy
1 . ' tr 'l' r it . . TODAY'S DATE
* "+'«
uz_al� $.250.00 Full Repair
'14Wi�
"xS CHO � $125.00.-Component
PAGE 2 OF 2
A. _ acllity.Information continued....
5. Typo•of Building: EJR7 sidentlal Dwelling or[DCommercial
E3. Agreement
The undersigned agrees to ensure the constructlon and maintenance of the afore-described
on-site sewage disposal system In accordance with the provlslons of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and trot to place the system 1n operation until u Certificate of Compliance has
boon lssued�y this Boned of Health.
Name Date
p ication Appr d By: Eoard of Health Re' resentaitly °
Date
Application Disapproved.for the following reasons:
For C�ffioe Uso �nlv°
11 Fee Attached?: Yes No
2:' Projectlllar agger C7h gatron Form Attacb'ed? yes®
No
43,: Perm ystem;� .Ifso)Attach cony of FYert r�l Pe r`t .i Yes® No
4. FoundationAs-Bq l't.?(new construction-ronl
W Yes® No
(Same scale as approvedplan)
.5: FloorPlansa(new construction only): No
Appl(c Hon�or•C7(spgsal Syst6mY dMtrudloh Permit Page 2 of 2
SEMC MTRM INVALIZZ'PROJECT MMGRMMT,X)BLIGATIOM
As fbeNgah Anduvexlk=sed bjima
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to thtappilmd"of
(Eat ceii Afid dMW
Dued
With MWOns dated
t rMse data)
I understaW the followbg ObUgadow for UW=9=cnt ofok project:
1. As the iasb&4 I
Am.obl*W io gab emu*ft and Bo
MA of Nealth 'Approved p1m pzbz to
f effouning xnfwolk da it Ditm.
2. .As flicWti jpj�tj' Jot SW gnd A*ptcdbn&. IE
and the qatain is narody,the'
Item duft,"bv pplicable.
b.As fii4 h��I amieqqw to haw 16 Oe*"q..WO&con:�*ttd-prlof.to theopplksbje inti
ctiog;as
�6$(Zeta
40im-dot heve to bc presbtie.
..b. Mint -etc,
AN to ox(ax i_mw.w. h6m the ei
-be to' D war- stlilli.r must
be t f i ;�t
6r th t*be.fe*and able to
carted. tl f *.h,hm?ccd* Vkh
tti l4ork x4d:slatmi. '0 u
must requW lwgcdo;Lw ''wava Imtdlct does not
.4. As•the 1ptallm-1 d dut ft
OAY4 W* MAWOVOCAMfopred
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