HomeMy WebLinkAboutHealth Permit # 11/4/2010 t! 4e �°° f �� Commonwealth of Massachusetts Map-Block-Lot
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Board of Health Permit No
North Andover BHP-2010-0755
P.I.
FEE
�sacmaos�s F.I. $125.00
DISPOSAL T I IT
Permission is hereby granted Daniel-R. Briscoe
to(Repair-D-BOX REPLACEMENT-1-120 ONLY)an Individual Sewage Disposal System.
at No 202 LACK STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2010-075 Dated November 04 2010
- - -- ---------------
Issued On:Nov-04-2010 Board of Health
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1
�i n n for fig _ 0
g I" TODAY'S DATE ATE
6— yF
Construction I
* � $250.00—P=ull Repair
$125.00 m Component
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Important: Application is hereb made for a permit to:
When filling out
forms on the U ion struct a flew on-site sewage disposal system*
computer,use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key
to move our „�.
y Repair or replace an existing system component—1fVhat7 ra;••r t,,
cursor-do not
use the return
A. Facility Information
key,
r
k Address or Lot
1-11 rty/Town
*TYPE O�SEPTIC SYSTEM*:
❑ rump ❑Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser(gavel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure [Distribution S.A.S. (No D-Sox) (Attach Draft Maintenance Agreement)
❑ Pressure [dosed (D-Box Present) S.A.S.
2. Owner Information
Name +— -+
(" ,e twf
(if{' different above
Address di )
"�
CitylTow State
� -�
Telephone Number
� $' ode
Zip C
3. Installer Information
ffi . I
Narne Name of Company
Address
e
City/Town � State f Zip Code
Telephone Number(Cell Phone#R if possible please)
4. iclnar Inf�rmati�n
Name Name of Company
Address —
City/Town State Zip Code
Telephone Number(Bestir&to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
r
01 , II
01 OR'
0 82 9
ik fication Lor Se
-Construction Permit — TOWN OF TODAYD TE
$ 250.00 m-Full Repair
ORTH ANDOVER,,-MA 01845 $126.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type Of BU esidential 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, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
Name Date
Application proved By: bard of Health Represent t'
7
a
Name EUV
Application Disapproved for e following reasons:
For Office Ug9_9gly-
1. Fee Attached? Yes No
2. Project Manager Obligation.Form Attached? Yes No
3. Pzim-nSvstetn? Ifso Attach con,vofElectTicalPermit 3es No
4. Foundation As-Built?(new construction roniy): Yes No
app.rovedplan)
(same scale as.
9. Floor Plans?(new construction only):
Application for Disposal Systern Construction Permit-Page 2 of 2
y� M
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
;P CAl `
f For plans by
(,vldr<ss nn
of septic syste
(l"nssaxe,cx)
Relative to the application of d t r"" i" �"
(lnskaller'=, i�.arizc) And dated
(Z. iginal(l .e
Dated With revisions dated
a} s date)
(Last revised darts)
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 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: he altltcleu�st(��)tx�wnc.�fnc,rtlar�c :, reE:.c.cr':�ux) 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 (other than simple excavation)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 fallowing 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, pries, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer,I understand that I am sole responsible for the installation of the system as per the
approved 121ans. No instructions by the homeowner,general contractor,or any otherersons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Dak.e)
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