HomeMy WebLinkAboutHealth Permit # 11/20/2006 Commonwealth of Massachusetts Map-Block-Lot
107.A 0 21 4--------
Board of Health Permit No
BHP-2006-0742
North Andover -----------------------
P.I. FEE
F.I.
$250.00
-----------------------
Disposal Works Construction Permit
Permission is hereby granted Mike_Reilly------------------------------------------------------------- ------------------------------
to(Construct)an Individual Sewage Disposal System.
atNo -44-CRICKET LANE-------------------------------------------------------------------------- --------------------------------------------
as shown on the application for Disposal Works Construction Permit No. -BHP-2-006---074--. Dated --November20,-2006
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Issued On:Nov-20-2006 Board of Health
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rr� Y rJr+r t Application r I C I t )
a1e� a� "9N'4
r'r..
Construction Permit TQ 'S DATE
` $ 250.00® Fun Repair
s 15 ANDOVER. $125.00 - Component
SA NU '
Important: Application is hereby made for a permit to:
When filling out
❑ Co tract a new on-site sewage disposal system* -
forms on the R ""m
computer, use U epair or replace an existing on-site sewage disposal s stem
only the tab key
to move your ❑ Repair or replace an existing system component—Wha ?
cursor-do not 0JUD
key the return A. Facility Information
y' TOWN f"r8= CR�'r�4 AP�i[�Cr�"ff::E�w
rob Address or Lot# --�- _ftP A TCtk IJ1,.
L4 ( I�( ��..o-r)Y`, HEAR r H - --
--
y�. d __
�-
cnrm Clty(Town
2.- *TYPE OF,,$ PTIC SYSTEM E N
❑ Pump V,16ravity (choose one)
;*ql pump system, attach copy of electrical permit to application' NOV 1 7 ()06
Conventional System (pipe and stone system)
❑ Infiltrator or Biodiff user(Gravel-Less) (Attach a copy of your certification t 'rasia_t:&qA%a
❑ Pressure Distribution S.A.S. (No D-Sox) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
maw_
roc.'
Name -- -------
"21,lry ---------------
Address(if different from above)
-------- - ----------------
CityfTown State Zip Code
------- ----------------
Telephone Number
3. Installer Information
Name Name of Company
" 1. (' ;
- ------ ---------
Address - - --
Cityffown -- State p Code
- �r �---
-- -------
e Zi
Telephone Number Cell Phone#ifpossible please)
4. Desianer Information
T e fName o
Company
q t �n- -gia �
Address _ _....._...- - .
City/Tow K -- —..- --- - State -- --- Zip
Code
a _n- �
Telephone Number(Pest#to Reach)
Application for Disposal System Construction Permit^Page 1 of 2
arrrM Application for Septic
4�N, 4U �a� TODAY'S DATE ------
Construction r it - TOWN OF
+ $ 250.00—Full Repair
& w°"K� ANDOVER, $125.00 -Component
CHUS
PAGE 2 OF 2
A. Facility Information continued....
5. T of �Ulldln Residential Dwelling or ❑Commercial
V g g
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, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
0'N 1XI
Name Date
y {
A lica �i A roved B -and of Health Representative)
pp ,9 pp Y� � p )
Nam = � Date �
Application Disapproved for the following reasons:
For Office Use Only:
Z Fee Attaclied? Yes L""" No
X/
2 Project Manager Obligation Form Attached. 'Yes No
3. Pump Svstem? dfso,Attacli copy ofElectrpcal Permit 'es No
4. Foundation As-Built. (new construction ronly): Yes �' No
(.dame scale as approved plan)
5: Floor Plans? new construction only):y): Yew 1110
Application for Disposal System Construction Permit^Page 2 of 2
12/20/2066 12:18 9786888476 HEALTH PAGE 02N2
s Ic syST)SN INSTALLER PROJECT MANAGEMENT iBI.IGATICA
As the North Andover licensed installer fot the cr�Ktstt7ac�ion fas the septiTn systeox for�e property at
(Address of septic i ymem) For plans by
Relative to 01c appucaxian of_/� -�7•'ia IQ 1J And dated.
(I11STt111�r`S flav7x:�
Xi i8 a
Dated f /� )f / //.7
I lJ ! ( t With mvWons dBYP.d
o axe pat mvised.date)
I understand the following ola ` tionis for MU19cment of tW9 projeG :
1. As the installer,I am obligated to obtain all pexnits atxd Boaxd Of H]elltbL aapprovect plans ptinr to
performing any work on a site. I xnu av e r !� d o '�►
heist_ c�oae®
2. .A4 the installer,T:xnua.,at call fat:any and qU in,;cpectiOus. If bOmeo ex,coax tox„project ranauager,or .y
otKer person not associated with tray company schedules an inspection and the system is not ready,them
item three sbaU be applicable.
3. As the installer,i am required to have the nec"sny work completed pt:or to the applicable inspections as
3aadicated bc]o�ar. o e" n o a items in accordance
w5_ -`tl�7ide 5 and tk a oarcl C s e t" t . Q[l a lcvi ed s me and/or
co pain
a_ yottotn of Bed Gera y,this i,4 the&st(1') inspection unless thew is a xe wall,which
should be dose first. The installer must request the itnspection but does not bave to be present
b. EvIll Most fitst do their inspection for elevations,tics,etc,
As-built of vetbal CSI{(or e-xnail to: no o lM r,—or)AOM the engineer must
be submitted to the Board of 1jealth,,after which insmIler calls for an inspection.tinge. Installer trust
be present for this inspection, With a pump system,all electrical work must be ready and able to
cause pump to worlt atxd ohm to function...
c, i G__ "d –Installer must=quest inspection when all grading i5 complete. Installer does not
have to be on-site.
4. As the installer,I understand that oo y I may perfo un the work(osber than Amplk excava os)and I am requited
to complete the installation of the system idcrll in the attached application.for installation. LLwther
and tha yr r d c s v x can
.real vial of the t d or of lice aerate in.the of
Nart u xcs to o s' vol d sa
5. As the installex, I understaod that I must be on-site during the performance of the following construction
steps:
ca. Derltdon rhos the °elemtion of the excgvadon Ims been mached.
b. rospecdon of the sand and sione ro be&wcd
ce Finalm,9pecdon,07 Dowd ofHeaft eigffor covsultant.
d lostWifion of tank, +V,'oyr,pipes,sretne, veoe,pump chamber,ref ginhW and other
componeors.
b. s e' er d r o aF >r tern. er
me Qf tjis obxl ,q-ig,A
Undersigned Licensed septic Installer: I/ vz0z (.Today's mat
s4 e
(lei atve®In t5..�__ " ,. a e–
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Z'd Z06E-9L AIHGoJ .M JE)egOIW '.IW 13O C)� 90 6Z AoN