HomeMy WebLinkAboutHealth Permit # 6/3/2014 ® Map
LVD,I, Commonwealth of Massachusetts -Block-Lot
104.60097
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BOARD OF HEALTH Permit No
North Andover -BHP-2014-06-40----
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FEE
$125.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-B-ateson---------------------------- -------------------- ---------------------------------------
to(Repair)an Individual Sewage Disposal System. bl —bo)�,
atNo 63 HAY MEADOW ROAD-----------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. MP-20147-064. Dated---June-02_,_2014--------
Issued On: Jun-03-2014 0
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ion for Septic,_Di,sposal System,
Construction Permit - TOWN OF TODAY'S DATE
NORTH ANDOVER, MA 01845 250.00–Full Repair
$125.00®Component
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use
F1 Bp replace 9 sewage p a y
system*
only t ab ke y eP air or replace an existing system component What?to move your
°` .
cursor-do not
use the return A. Facility Information
key. .
--- ---- -----------
Address or Lot# --
--- --------
City/Town i M rt �pd e
2.-*TYPE OF SEPTIC SYSTEM*:
> ❑ Pump [9'Gravity(choose one) TOVUI i FI
***If pump system, attach copy of electrical pen-nit to application*** l I I I DE FIAI
> EFConventional System (pipe and stone system) ®
➢ ❑ Infiltrator or Biddiffuser(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
Name - ------- --------
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name of Name of Com U
N E`T�'nf"nIS =.�,INC.
,�
111 ARCILLA 1-30AC) _—_—___--.--
i
Address
City/Town State C �__--_�Zip� odeY
--
Telephone Number(Cell Phone#if possible please)
4. Designer Information
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
Application for tip i I t
' TODAY'S DATE
Construction Permit — TOWN OF
250.00-Full Repair
$125.00 -Component
PAGE 2 F
A. Facility Information continued
es ".
5. Tyne of ullding: ®1 .��~�ld ential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. l understand that until a final Certificate of Compliance has been issued by
this Board of Health the installed system is not approved.
Name r — Date — ----
.._ p
App l�ca#i� A (Board l�aard of Health Representative)
Name, -- — Date — -- - —
Application Disapproved for the following reasons:
For Office Use ®nlv:
L Fee Attacheda Yes No
2. Project Manager Obligation Form Attached? Yes No
J. Pump Svstem? If so,Attach copv ofElectri'cal Permit Yes No
4. Revieived approval letter, all paperwork received. Yes No
Missing:•
5 Foundation As-Built?(new construction only); Yes No
(Same scale as approved plan)
6 Floor Plans?(new construction only); Yes No
Application for Disposal System Construction Permit.Page 2 of 2
SEPTIC S,Y.$Tl' M.•INSTALL-'�k•PKGJECT MANA�GEMEN'T OBLIGA'T'IONS
As tl}e•North Andover•licensed.in§taller for the:constructiori'fcitlhe septic system;for.the:property at
(Addresi of septic system) For plans by
(En ' eer)
Relative to th6.application of l ai# cr °� Aad dated
(in'staller's name)
ae .
Dated 1a�° c °� With revisions dated 71 a
ociay s MR.) (Las Frews e idate)
I understand the following obligations for management of-this project:
1. As the installer,I am.obligated to obtain•all permits and Bbard of fHealth approved plans.prior to
;performiag any'work on a site: I must have the pproved plans and the•permit:on site when any work is
Ung done,
2. As the installer;.I.mu'st,call-for any and all:inspe-edons: I£homeowner,contractor,•project maudger, or any
other person not associated with my company schedules•an inspection and the system is not ready,then
item three-sh4 be.applicable.
3.`' As•the ustihex,'I atzi••requ ed to,have the geci:ssary work•completed.prio to the,applicable inspections as
indi
r, «:any*��,a rt,g r,: n ins c. d n, oui cbmlilefion•of the- in accordance
cated belowy ,.._.d.... 4' p -
'tvitli T'itle�and'#h�; � . . itk}fie ti�i•��,ay�esu7�':ina�SO'00'frie•lir.3��1Q. evied•�gainstme and'/or
Bo'tiom bf•1E3ed Generally,this is the-RiO.(. 1).1n'spietioxi•ttnl�ss;there is a retaining wall,which
should-be--.Ab Arst: Thctuista4fihustte�gpest flit itispecti6a but cloes•riot have to be ptesent: .
b. Fin o'n ' * riecti o '—Enghieer must first iia their;Yiis ection for elevati ons,.-do,-etc.
As-l�iiilti of verbal OK'(or e-mail•to:health n {to 0 orthandover.�om'from the engineer must
be stibmitfedlo-..the,Bo'ard'of1-Iealth,alter'-w- .d}i.installer•calls f'or•tin insp'ectipn tune. 'I staller must
be present for this.inspection, with a pump system,all elecCrical work must:be ready and able to
cause pump to work and•alarJn..to funOdon..
c. .FinatGmd •—installer must tequest'inspccdon vvheii' ll grading•is'complete., .Installer'does not
have to be•on=site.
4. As-the installer,'I und�fstand that only I•Itay pexform the avozk'(other than iiwple excavation)and'1 ani required
to complete the•installatitin of the system identifier in tlii•attached.application;for.itistalladon.' .LW tli'e
pnders#and:that work done'by.otli'ers uiiii'cense�i t ins se tic,sysfems•in Nnrtli And can con'sdtute•
reasons for deival of tht system andlor gvocation o'r su 5ension of•my license•to opetate iti.tlie T:oam of
North Andover,significant fines.to all Verso'ns-iufvQlvetj pare also e, v.
5.. .As the.instiller, I understand that.I;ntist be'or<=,site during th •perf&niance•of the•following constYUCrion.
steps:
a: Detenrzrnaddd that,tbe properelevadan of the ekc-4ratron has beers reached
b. Inspection of the sand and stare-to be used.
c. Fina kgpectrorr by Boat'of. ealth staffor conq,&=4
d. Installatron.•of tank
,D-Boxf pipes,stone, vent,primp chamber,retarrrg walland other .
component4.
6. As the installer•WW* rstand that I:am sbIdy r&,apRnsible for the installation of the cyst as per the
apgroeed pYans. No instructions by the Homeowner,general.contral nr ley rirlitr.r� rcnnre hall-absolve
me 2EWs obligation.
f
Undersigned Licensed Septic.Installer: p a I) tie d 91
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