HomeMy WebLinkAboutHealth Permit # 3/30/2012 Map-Block-Lot
Commonwealth of Massachusetts 107.A0130
® -----------------------
BOARD OF HEALTH Permit No
BHP-2012-0544
North Andover -----------------------
P.1 FEE
$250.00
F.I. -----------------------
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Todd Bateson
to(Repair)an Individual Sewage Disposal System.
atNo 332 RALEIGH TAVERN LANE -----------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2012-054 Dated.__March 30,2012------
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Issued On: Mar-30-2012 BOARD OF HEALTH
rr °
tic 1 TOt7ATS DATE
to ,spade.a ,� o� % r
250.00—Full Repair
4� tlp� 4f a 845 $125.00.Component
4 y�MAM✓�
sACw+u
important: Apc�licatian is hereby made fiat a permit lu
When filring out ®Construct a new on-site sewage disposal system*
farms on the
computer,use N4epalr or replace an existing on4ite sewage disposal system*
only the tab key
to move your Repair or replace an existing system component®Vilhat7
cursor-do not
use the return A. Facility Information
key. ! `` V
m Address or Lot#
* PE OF SEPTIC SYSTEM*:
;
pump U Gravity(choose one}
***If pump system,attach copy of electrical permit to application***
onventional System(pipe and stone system)
infiltrator or®iodiffuser(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
Name
Address(if different from above
AP 69 A1115
Cityrrown State C Zip Cade
Telephone Number
3. Installer Information
r
{• Name of Co an 111 ARCILLA i0 � 1
4 r� C7N DR!'I I? �� ,
Name C7d�C,�
/ P y ANDOVER,MA 01 ffl 0
Pddress
Cityrrown
State' Zip Cade
Telephone Number(Cell Phone#ifpossiblepleas se)
4. ®esioner Information
Name A
Name of Company �—
Address
witylfown Stake zap Cade
Telephone Number(Bast#to 'each)
Application fat Cisposat System construction Permit.Page 1 of 2
°RTH Application for Septic Disposal System 1 - -
`' TODAY'S DATE
pC.onstruction Permit ' TOWN. OF
* $.250.00—Full Repair
-ORTH ANDOVER, MA 01845
$125.00 -Component
,SSACHusE
PAGE 2OF2
A. Facility.Information continued....
5. Type-of Building: Residential Dwelling or EGommercial
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 issuedby this Board of Health.
d
Name Date
Application Ap 9 d By: (Board of Health Representative)
Name Date
Application Mapp oved for the following reasons:"
For Office Use Only:
1 Fee Attached. � Yes No
2.. ProjectMatiager Obligation Form Attached? Yes No
A: Pump System? Ifs03 Attach copy ofElecttical Permit`. Yes No
4. Foundation As Built?(new construction-ronly),- Yes_ No
(Same scale as approved plan)
5. F1oorPlans?(new construction only). Yes_ No
Application for:mposal System Construction Permit-Page 2 of 2
M
YSTE.M INSTALI;ER PROJECT ANAGEMENT' OBLIGATIONS
SEPTIC S
the North Andover.licensed installer for'the construction for:the septic system:for.the property at:
As _
. �' p For plans by
(Address of septic system)
(Engineer)
Relative to the.application of �d' I And dated
(in'staller's name) ngina ate .
Dated �Q With revisions dated t ®�
o a s ate (Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am.obligated to obtain alI permits and Board oan � eprmit on plans
te whe n an�work is
:performing any work on a site. I must have the a rowel' lan
b'eine done.
2. As the installer,.I.miist call for any and all:inspe�tions: If homeowner,contractor,.project manager, or any
• erson not associated with my company schedules an'inspection and the system is not ready,then
other p
item three-shall.be.applicable.
3.4 As die'installer;I atxi'required to.have.tlie necessary work completed prioi: the.applicable inspections as accord
indicated below: :I undefstand that re uestin an uts,ection without coin .l b oirni 1 viedta ainst mea d or
with Title 5 and the Board of plealtli Reyulahons may result X50.00 fne
my e-. 9mUa nV- g . :
a.Bo`tfo'm of Bed Generally,this is the first(1 `j tnspec60' unless.there is a retaining wall,which
p
shfltilcT be done=first. The installer must request the ihspectiofl but aloes not have to be .resent.
b. Final Construction Inspection—Engineer must firsi.do their:inspection for elevations,--des,
etc.
As-biult ofwerbal OK(or e-mail to:Health etitCi5townofnorthandover.coin).from the engineer must
be submitted-t(5.the Board•of Health,a-t.r.which:installer.cails for an inspection time. 'Installer must
be present for this inspection, With a pump system;all electrical workgmstbe ready and able to
cause,putrip to work arid.alarm.to fatiction..
c. Final Grade—,Installer must request inspection vvheiill 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 lam required
to complete the•installation of the system identified in.the,attached application for.installation: .I fiitther
understand:that work do .others uiliceiised to install se tics stems•in North Andover can constitute
reasons for denial of the s ste and or`:revocation or sub' eris'ori of•m license:to o erate.in.the Town.of
North Andover sig*i iAcant fines to all'liersons involved are also'uossible.
5.. As the:installer,T understand that:I must i�e'on�site during the.performance of the•following construction.
steps:
a. Defetruitratio -that.tfie proper elevation of the cyreava.tron has been reached.
b. Inspection of the°sand and stone to be used
c. Final inspection by Board ofHealth staff or consultant.
d. Installation.,of tank,D-Box;pipes, stone, vent,primp chamber,retaining wall and other
components.
6. As the installer.I understand that I am sblely responsible for the installation of the system as per the
a roved Tans. No instructions b the'homeowner eneral.contractor or an '.other ersons shall absolve
me of-this obligati on.
Undersigned Lice:�sed Septic.Installer: oda 's Date)
ame:= .ring
a�