HomeMy WebLinkAboutHealth Permit # 12/7/2010 Commonwealth of Massachusetts Map-Block-Lot
038.00 25 4
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0 Board of Health
Permit No
B
North Andover HP-2010-0777-----------------------
FEE
SSAC 'LIS $125.00
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ISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-Bateson-----------------------------------------------------------------------------------------
to(Repair-D-BOX&OUTLET TEE ONLY)an Individual Sewage Disposal System,
atNo -4-8-1-REA--STREET------------------------------------------------------------- ------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. .13HP-20107077--- Dated.--December-0-7,-2-0-1 0-
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Issued On:Dec-07-2010 -9-da-rd--oMalth
o.0of11 Application for Septic Disposal System / ®1
' TODAY'S DATE
oAConstruction Permit ® TOWN OF
' • �� ORTH ANDOVER, MA 01845 250.00-I=uli Repair
$125.00-Component
fir& CIKU
Important: Application is hereby made for a permit to:
When filing out Construct a new on-site sewage disposal system*
forms on the
he tab key El Repair or replace an existing on-site sewage disposal system*
only Y T l Imo'
to move your air or replace an existing system component—What? �—
cursor-do not
use the return A. Facility Information
key. q l Y 5e'l 5�'
IG-�I Address or Lot#
Cityfrown JVd
2.-*TYPE OF SEPTIC SYSTEM*:
❑Pump ravity(choose one)
***If pump system,attach copy of electrical permit to application***
onventional System(pipe and stone system)
❑Infiltrator or Blodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
C 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)
Cityl1 own State Zip Code
Telephone Number
3. Installer Information
Name Name of Company 11 A ES,INC.
ANDOVERL nQROAD
Address c
City/Town State Zip Code
`71r �/s= J°7v�
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
a°�7H Application for Septic Disposal System 1 �1
:' °c '
-Construction Permit TOWN OF TODAYS DATE
•' ORTH ANDOVER MA 01845 $250.00-Full Repair
� °•..° %'"� ' $125.00 -Component
PAGE 2OF2
A. Facility.Information continued....
5. Type'of Building: 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 is Board of Health.
Id/
Name Date
Application Ap r'ov08 By: (Board of Health Representative)
Name % Date '
Application Disapprove for the following reasons:
For Office Use Only:
I Fee Attached. Yes No
2. Project Manager OhEgation Form Attached. Yes No
3. Pump System? Ifso;Attach copy ofElectrical Permrt` Yes No
4 Foundation As-Built?(new construction ronly); Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only); Yes_ No
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:
(Address of septic system) For plans by
n /�� (Engineer)
Relative to the application of �� LAC
(Installer's name) And dated Y�
ngtna
Dated !�—I j 6
o ay s ate With revisions dated a
(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: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 reauestin an inspection,without completion of the items in accordance
with Title 5_atnd 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 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. Firnai.Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to: healthdel2t@ ownofnorthandover com) from the engineer must
be submitted to the Board of Health, after which installer.calls for an inspection time. Install er roust
be present for this inspection. With a pump system, all electrical work.mustbe 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:rim ple excavation)and I am required
to complete the installation of the system identified in the attached application for installation: I f6rthex
understand:that work done by others unlicensed to install se .tics stems in North Andover can constitute
reasons for denial of the system and/orrevocation or suspension of my license to operate in the Town of
North Andover sizWficant 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. Detetmrnatioa that the proper elevation of the excavation has been reached.
A 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,pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as 12er the
a roved plans. No instructions by the homeowner, eneral.contractor or an other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer:
f
7*4
(Foday's Date)
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