HomeMy WebLinkAboutHealth Permit # 3/24/2010 Map-Block-Lot
µ4RTk Commonwealth of Massachusetts 038.00127
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,:� ' 4 Board of Health Permit No
p BHP-2010-0524
North Andover -----------------------
.y FEE
4 P.I. $250.00
�SSs Ft F.I.
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted -Mike-Reilly----- -----------------------------------------------------------------------------------
to(Repair)an Individual Sewage Disposal System.
atNo -268 REA-STREET-------- ---------------------------------------------------------------------------------------------------------------
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as shown on the application for Disposal Works Construction Permit No. BHP-2010-052 Dated March 24,20 10------
Issued On:Mar-24-2010
Board of Health
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— - --TODAY'S DATE
D TE
nSri Permit ® °
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$1 .e Component
Important: Applicationis hereby made for a permit to:
When filling out [1;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
key.y the return A. Facility Information RECEIVED
&a I Address or Lot#
60(m
�rxn City/Town -------------- _ G bt r'V(,DF[NO O 1
8'N B P 91 i C"kd i /\N (fu9r
2.�*TYPE OF SEPTIC SYSTEM : �,�,� �.,, W,,,
Pump ❑ Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
❑ ventional System (pipe and stone system)
Zrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ pressure Distribution S.A.S. (No C-Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
Name
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Address(if different from above)
City/Town State Zip Code
,.. a
as
Telephone Number
3. Installer Information
cj_]
Name Name of Company
Addryss,,//nn ---------------— -- --
4.)_ li l
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Pq§jgpgr Information
Name Name of Company
Ad, Tess
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit^Page 1 of 2
ndo. „ Approcation for tl c Dis osal S stem
w TODAY'S DATE
t °AConstruction Permit — TOWN OF° CJ ` ' g 01$45 �250.00-Full Repair
� $125.00 -Component
PAGE 2 OF 2
A. acility Information continued....
5. Type of Buildin Residential 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
Applicatj(in Approved By: (B ,ard of Health Representative)
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ry„� �.
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Name Date
Application Disap£prdved for the f (lowing reasons:
For Office Use
L Fee Attached? Yes - No
2 Project Manager Obligation Form Attaclied? Yes No
3, Pump sy tezn? Wso,Attach copy afElectrical Permit Yes< No
4. Foundation As-Bu;A? -rn6W construction► ronly): Yes No s
(Same scale as approved plan)
.. Floor Plans?(near construction only): Yes � No”'
o"'
Application for Disposal System Construction Permit-Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
t�'d c's c�rl�.f pla ��s am) For}Mans by
gy j /
And dated
Relative to the application of �d��1 }'�'�B e r l/!�
li ,y,�
ati�toaF� � Mfr
Dated
With revisions dated
(_as0. revis(ai chic;)
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 PAor 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-,vitli 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
mcompany.
a. Bottom of Bed—Generally, this is the first (V5 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 OK (or e-mail to: from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection tithe. Installer must
be present for this inspection. With a pu np 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 excavatzotl)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,purrap chamber, retaining avall and other
components.
6. As the installer,I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: "
Date. ...
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PERMIT FOR WIRING
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This certifies that ,,. . L1,1) 7 /°.{ c .............
has permission to perform ,..,. rf,
wiring in the building of,.,,. 0
.............................�;North Andover,Mass.
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Fee.... ... ..:..... ].,IC.1�10.
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Check # (0
9295