HomeMy WebLinkAboutHealth Permit # 4/5/2007 Map-Block-Lot
40p r#4 Commonwealth of Massachusetts 106.A-0069-
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Board of Health Permit No
0 BHP-2007-0056
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North Andover
FEE
P.I. $250-00
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F.I.
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C -Lot
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0
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Disposal Works Construction Permit
Permission is hereby granted Todd-Bateson ----------------------------------------------------------------------------------------
to(Repair)an Individual Sewage Disposal System.
atNo 23 FOREST STREET ---------------------------------------------------------------------------------------
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as shown on the application for Disposal Works Construction Permit No. .13HP-20077005- DatedMarch2-2L2907------
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Issued On:Apr-05-2007 --------------- ogd
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P1
� I I t
nine' I�'It' r� r t I/
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1 o TODAY'S DATE
p Construction Permit
$,250-.00—Full Repair
$125.00 ° Component
Important: ,application is hereby made for a permit ta:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer, use @4epair or replace an existing on-site sewage disposal system*
only the tab key �f
❑ Repair or replace an existing system component
to move your �
cursor-do not
use the return
A. Facility Information '��p f
4
key. _
Address or Lot# —-----_---- 1�-_a"
City/Town ^ �.
iron - --- — — - —--------
2.- *TYPE OF SEPTIC SYSTEM*.
❑ Pump cavity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Diodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D°Box) (Attach Craft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present)S.A.S.
2. Owner Information
Al -- - -----
Name
Address(if different from above)
Citygown Stat Zip Code
Tel phone Number
_
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3. Installer Information
_� ..Je
Name Name of Company
Address
vc.1"--------- --- "� Zip Code.,-
--_—
City/Town State
Telephone N
umber(Cell Phone#if possible please)
4. Designer I rorma tlon
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.� ..
u..-.4 a.
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Name Name of Company rn
Address
CitylTown State Zip Code
-1 °° ,.7 ';3
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
4 P141<I!e qN�t ®®te�aa p� g gp TODAY'S DATE �p
�IRv ' n 1 p� 1 1 I
f p Construction Permit
NORTH $ 250.00 d-Full Repair
F.. 4 $125.00 -Component
PAGE 2 F2
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 Andoy r, and not to place the system in operation until a Certificate of Compliance has
been iss d. y this Board of Health.
oy m
Name,°" Date —
Appiic ati�a prave�d By ,Board of Health Representa tive)
w
_
Na�Z Date a'
„
)�plica(ion Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Project Manager Obligation Form .Attached? Yes No
3. Pump System? If so, Attach copy of Electrical Permit Yes_ No
4. Foundation As-.Built?(new construction ronly): Yes No
(Same scale as approwd plan)
S. Floor Plans? (new construction only): Yes_ No
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
r
5/.
(-Address of septic system) For plans by
(Engineer)
Relative to the application of li'
(Installer's name) And dated /
ngina ate
Dated
o ay s ate 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 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 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
my company.
a. Bottom of Bed—Generally, this is the first'(V5 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. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK(or e-mail to: healthdel2t@townofnorthandover.com) from the engineer must
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 simple excavation)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 Healib 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 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: (Today's Date)
3
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ame— rint (Name Signe