HomeMy WebLinkAboutHealth Permit # 4/11/2016 -------------------
Commonwealth of Massachusetts Map-Block-Lot
107.B0133
BOARD OF HEALTH -Permit-No----------
North Andover -BHP-2016-0065
FEE
$175.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Pet-mission is hereby granted Neil-1. Bateson---------------------- ------------------------ ---------------------------- ----------
to(Repair)an Individual Sewage Disposal System.
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at Na -14-PURITAN-AVENUE-------------------------------- ----- -
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as shown on the application for Disposal Works Construction Permit No. BBP-2016-006 pD 0--A—PT! I,2016_
- - --------------- ---- --
r7)
Issued On:Apr-11-2016 BOARD OF HEALTH
tion for i i I /V-- ~—le,
TODAY DATE
Construction
250:00 m dull Repair
$125.004®Component
Important: Application Is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal systern*
farms on the
computer,use ❑Repair or replace an existing on-site sewage disposal system'
only the tab key epair or replace an existing system component—1rWhat?
to move your
cursor-do not
use the return A. Facility Information
key. �C P"i �T.9 a/µ
Address or Lot# f
t� l
Cityrrown
2.-*TYPE OF SEPTIC SYSTEM*: /PRI �
> ❑ Pump ravity(choose one)
***'If pumps tem, attach copy of electrical permit to application** I�� ;i I ft�� "'
➢ Conventional System (pipe and stone system) E sf. l,.l f i af'1 ,
➢ E]Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this yp�i (em.)
> ❑Pressure Distribution S.A.S.(No D-Box)
> ❑Pressure Dosed(D-Box Present)S.A.S.
9 ® Does the system require an effluent filter? Yes No
If yes, does plan specify malice and model of filter? YES=(no further info. needed)
NO®(installer must specify brand of filter before DWC issuance)
What is the Make? Wizatis dieModetl
2. Owner Information
Name
Address(if different from above)
/4P,4
Cityrrown--� State Zip Code
Telephone Number
3. Installer Information
Name Name of Com ,
� �°� hl�llt�jlr�p..r:� S'INC.
/// / ANDOVER MA 0181'r
Address �� �� �I��I�S'i Cf
Cityrl'own State Zip Code
C"/X r vii ..-
Telephone Number(Cell Phone#If possible please)
4. Designer jnforrnation
Name Name of Company
Address
Cityrfown State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Pem7ft+Page 1 of 2
FIN )i i ti i o TODAYS_pq�yp
Go
. - $.zsa.®® Full Repair
�. r ANDO
R� $125.00.®Component
94"V
$ACHU+
PAGE 2 OF 2
A. aciiity•Infer � ior� c�ntinu�d....
S. Typo'cif uH nq: esidential Dwelling or Elcommercial
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!Mode, as well as the Local S'ubsurfdce Disposal Regulations for the Town of
North Andover, and not to place the system In operation until a Certificate of Compliance has
' Health.
been lr�rgd by this Eoard ofHe........
Nam pate
plic �tion Ark ra By: lard of Health Representative)
Name ...., a e
Application Disapproved,for the following reasons:"
For Off[ce Use Only: ;..
1. Pee Attached? Ycs Nam
2:. Prajectli "agcr Clhvgadon.Form Attached? Yea
3,: Purno S'vstem� 1'fsoj Attach cove ofEIectri%cal Perrrrxt`,,t Yc� No
4, pnuadadon -Built?(new eo �struct%on�ronly): Ye�s� No
(S scale as appraveF plan)
.5: FloorPlaris?(new construbtlon only): Yes No.®
A,pplfcatidn for:0116, Oat 4ystet�h 06nstractloei Permit>Page 2 Of 2
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