HomeMy WebLinkAboutHealth Permit # 11/6/2014 Commonwealth of Massachusetts Map-Block-Lot
® 105.D0167
BOARD OF HEALTH - - --------
Permit No
North Andover BHP-2014-1284
FEE
$250.00
DISPOSAL WORKS CONSTRUCTION I7"
Permission is hereby granted Robert-K Daigle_______ _ _____________
to(Construct)an Individual Sewage Disposal System.
at No --143 LACY STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2014-128 Dated November 06,2014
- - ------------------------------
i ;
BOARD O -
Issued On:Nov-06-2014 F HEALTH
ation for a I y
Y' DATE - -- �
Construction — TOWN F TODA
01 4 $250.00-Full Repair
y , $125.00 -Component
Important: Application is herebv made for a permit to:
When filling out ❑ onstruct 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
use the return A. Facility Information key. d
rah Address or Lot#y
reran ity/Town -
2.- *TYPE OF EPTIC SYSTEW:
❑ Pump YGravity (choose one)
***If pump system, attach copy of electrical permit to application***
conventional System (pipe and stone system)
❑ Infiltrator or Biodiff user(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
111-4
Nam �
Ad s d ent fro bove
C�ty n _statj Zip Code
'
..,. 1 r,
Telephk ,-
o_ne Number
3. Installer Information .
Na a Name of Company
Address
. . - ' '
Cityffown State Zip Code
Telephone Number elyhone#i possible please)
4. Qesi r Information
NameT Name of Company
Addre s
Cityffown State Zip Code
Tel phone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for
TODAY'S AT
sConstruction Permit — TOWN OF
'�, �7 01 4 $250.00-Fun Repair
° $125.00-Component
PAGE 2 OF
A. Facility Information continued....
5. Type of Building: MResidential 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 Cade, as well as the Local Subsurface Disposal Regulations for the Town of
North Andovervj�,and not o place the system in operation until a Certificate of Compliance has
been issued rd of Health.
, /, -- - � r -- ---
Na a Date
pp li a Lion A p r_ e y6 : (ea rd of Health Re p resentative)
Name Date
Application Disapproved for the following reasons:
For Office Use Pnly:
Z Fee Attached Yes No
mgr'
2. Project Manager Ohligation Form Attached? Yes � M No
3. Pump System? If so,Attacli copy of Electrical Permit Yes No
4. Foundation As-Built?(new construction ronly): Yes No
(Sarre scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATICJNS
As the North Andover licensed installer for the construction for the septic system for the property at:
(<Acld rs «��selar
A-.4,0 tatm1 For plans by f l' w
Relative to the application of x a + 'A "
(Inst allcr's nap And dated
rctr,auza <<aP�e
Dated /' izi
c:ury�ti c are With revisions daated
(Last rc6sc°c1 (1,11c)
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 rp for 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, I 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 trust 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: h ,ul,.11.(;ia la,l;.( from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection tirne. 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 (other Man simple excavalion)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.
G. As the installer, I understand that I am solely responsible for the installation of the system as per the
al2proved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: ("l'caclt}'s 1) dte)
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