HomeMy WebLinkAboutHealth Permit # 11/3/2011 ' � • Commonwealth of Massachusetts Map-Block-Lot
BOARD OF HEALTH 1o8.A0002
North Andover Permit No
P.I. BHP-20o1f
1-0815
F.I. -----------------------
—_ FEE
$
DISPOSAL 250.00
-----------
WORKS CONSTRUCTION PERMIT
Permission is hereby granted William Sawyer
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to(Construct-NEW SEPTIC SYSTEM)an Individual Sewage Disposal System.
at No 2009 SALEM STREET
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- ----- --------
as shown on the application for Disposal Works Construction Permit No. BHP-2011-081. ,_
--- ,Dated November"03 2011
f 1
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Issued On:Nov-03-2011
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BOARD OF HEALTH
i
lal icationfora2pLlc Disposal System _f 0DAYS DATE
Construction Permit — TOWN OF
ORTH ANDOVER MA 01 $125.00-Component
Important: ADDlication is-h6ebv made for a permit to:
When filling out n�zuotancmoon^s�e sevvogedkspns�gsyscenm' /��
�nnoon�e --
computer,use Fl Repair or replace an existing on-site sewage disposal system*
only the tab key �
m move your El Repair mrreplace aneximt|ngsystamnownmponant—VVhmt?
cursor-gonot
use the return
A. Facility Y Y X
key.
twn City/Town
2.-* ���Foose one)
F 1 !*�—' �� attach m|mctdcaipennbhomppUomt\onw*
npump����nn, �cuu °.
2, �lConvendono|Mymbymn (pipaondstonwsyetenm)
Fl |nfiUrmbororG3\od|fTusar(Grmve|^Less)(Attaohaoopyofyouroedihosdiontoinsta||thiotypeofeye\em.
F-1 �Pressure (No D-Boo) (A�anh Draft NYm\nbmnmnooA8reennant)
rae�u
[l Pressure Dosed (D-Box Present)S.A.S.
� 2. Owner Informatio
4 State Zip Code
City/TdWn A/
Telephone Number
Installer,Informiltion
ev
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Cell Phone a if possible please)
.. Desic
Name of Company
Name
Address A/
ode
City/Town State Zip C
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit Page 1 of 2
M!on for
A 2 2.R' a t
TODAY'S DATE
-Construction Permit - TOWN OF
$ 250.00-Full Repair
ORTH ANDOVER. MA 01845
All. $126.00-Component
C
PAGE 2 OF 2
A. Facility Information gontinued....
s. Type of Building: E�6<esii I dential 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.
ZC>
Name Date
A/-01i!ca ior/ ti "Approved Byl- 0
(Board ,Health Representative)
ame p,
y
Date
Application Disapproved for the following reasons:
For Office Use Only:
L FeeAttacbed? Yes No
Y
2. Project Manager ObAgation Form Attached? es V1 No
3. amp System? ffso,Attach conv ofElectrical Permit Yes— No
4.
Foundation As-Built?(new construction ronly): Yes No
(same scale as approvedplan)
�Floof Plans?(new construction only): Yes No.Ym
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:
For plans by
(Address of septic systern) (En inee
Relative to the application of
>
And dated
(Installer's name) ripll a a.<
Dated With revisions dated
0,ay s C ate (1_,,ast 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 Rgfor to
performing any work on a site. I must have.tb"a proved plans and the permit on site when any work
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 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 aanst me and/or
my company
a. Bottom of Bed–Generally, this is the first (1'� inspection unless there is a retaining wall,which
I
should be done first. The installer must request the inspection but do es not have to be present.
b. Final Construction Inspection–Engineer must first do their inspection for elevations, ties, etc.
northand from the engineer must
.Lover.mtni)
As-built of verbal OK (or e-mail to: Qver —
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump 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 shv1ple excapation)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. ti
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, pi p chamber, retaining wall and other
pipes, stone, vent,pum mb
components.
6. As the installer,I understand that I am solely,s responsible for the installation of the system as per the
a roved plans.,No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: r�/ �, ("l'c>clY's I7at:e)
<r me igned)
TNanie