HomeMy WebLinkAboutApplication - 295 REA STREET 8/9/2012 stem
TODAY'S DATE
250.00—Full Repair
$125.00-Component
�Z..
Important* Application is hereby made for a permit t :
when filling out ® Construct a new on-site sewage disposal system*
forms on the
computer,use 81kepallir 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. "'419S
Address or Lot#
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2.®*TYPE OF EEPTIC SYSTEM
®Pump Gravity(choose one)
***If pump system,attach copy of electrical permit to application***
®Conventional System(pipe and stone system)
nfiltrator or®lodiffuser(Grave[PLess) (Attach a copy of your certification to install this type of system.
Pressure Distribution S.A.& No D-Box)(Attach Draft Maintenance Agreement)
Pressure Dosed(D-Sox Present)S.A.Q.
2. Owner Information
Name ;
Cis ..
Address(if different from above)
l " °. . ... e ) r
city/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of C N Al nalAwwo"I 4MI-F
MWmPRISES,INC.
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� � .._ �' �. f t 1
Address MA 01010
To—frown State' Zip Code
VYY t
Telephone Numb ell Phone# f p asibl
please)
4. Designer Information
Name Name of Company
Address"
City/Town State . Zip Code
Telephone Number(Best##o Reach) .
Application for Disposat System Construction Permit«Page 9 of 2
pORTi,
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�:+ .°• op TODAY'S DATE
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-ORTH ANDOVER., MA 01845
$.250.00"Full Repair
ACHUS $125.00,®Component
PAGE 2 OF 2
A. Facility.lnformation continued....
5. Type-of Building: esidential Dwelling or OCommerciai
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 .r.......... Date
A PP pp
Application A v'',day: (Board of Health Representative) x
Name Date
Application Disappved for the following reasons:
For Clffi'ce Use Only:
1 Fee Attached? Yes No
2, Projectltlariager ObEgation Form Attached? Yes No
3.: Bump-&S-tem.? Ifso)Atta ch conEofElectdcalPerrnrt` 4 Yes No
4 Foundation As-Built,?(new construction ronly), YeS® No
(Same scale as approved plan) —
A Floor Plans?(new construction only), ;yes_ No
Appilcation for Dlspasai System:Gonstruction Permit a Page 2 of 2
SEPTIC SYSTEM INSTALL PROJECT MANAGEMENT,OBLIGATIONS
As the North Andover-licensed installer for the construction for:the septic systemf6t the property at:
For plans by _
(Address of septic system) (Engineer)
Relative to the.application of And dated
(installer's name) nginalclate .
Dated %-"/ With revisions dated
(Last revised date)
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 prior to
:performing any work on a site. I must have the approved Mans and the pernut'on site when any work is
being done•
2. As the installer,.Lmust call for any and allanspections: 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•b e.applicable.
3.'% As the installer, I atxi-required to.have.the necessary work completed priof to the.applicable inspections as
indicated below: I tiitdeistand that re ueshng an inspection without comyletion:of the-items in,accordance
with Tile 5 anti the Board of Health Regulations may result in a$50 OO fine bein�.levied agatnst:in and/or
inv_eompany.
a,. Bo'tfom 6f B.ed Generally, this-is the iirst(1'�inspection unless.there is a retaining wall,which'
should be done first. The`insta4i iinttegpest the inspection but cicies not have to be present.
b. Final Construet%ri.Iinspectiofi—Engineer�riust—f st.do theirinspection for elevations;ties,'etc.
As-built ofweTbal OK(or e-mail io:healtl delitOtownofriorthandover.com):from the engineer must
be stibniitEed to.the Board Health,after'whicli:insthiler.calls for an inspection time. Installer must
be present for th.is.inspection. Wlitha pump system;all electrical work nn-ustbe ready and able to
cause pump to work arid,alarm to function..
c. FinalTGfade Installer must request inspection when 4ll.grading•is complete._.Installer does not
have to be•on=site.
4. As-the installer;I understand that only I fray perform the.woik'(other than:rimyple excavation)and I am'required
to complete the-instillation of the system identified in the..attached. pplication for.installation:'.I further
understand.-that work done by others uhliceiised.'to-install septic systems in North Andover can constitute
reasons for denial-of the system and%or'�fevocation or sus6enss oti of.my license:to operate in the Town.of
North Andover si�mificant fines to all persons involved.are also possible.
5.. As the:instiller,J uiderstand thatI must be on-.site during the.perfonriance.of the following construction
steps:
a: Determination that.theproperelevatron of the excavation has been reached.
A Inspection ofthe sand and stone to be used.
c, Finalinspection by Board ofHealth stafforconsultant.
d. Installation,of tank,D-Box;pipes, stone, vent,primp chamber,rctaiAhW wall and other
components.
6. As the installer,I understand that Tam solely responsible for the installation-of the system as per the
approved-Wans. No instructions by thehomeowrier,general-contractor.-or any.other:persons shall-absolve
me of this obligation.
Undersigned Ilceased Septic.Installer: (Today's Date)
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