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HomeMy WebLinkAboutHealth Permit # 8/1/2014 4t�ct", Commonwealth of Massachusetts Map-Block-Lot 106.A0013 BOARD OF HEALTH _____ -- • Permit No North Andover BHP-2014-0728 ---------- P.I. FEE F.I. $250.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John Butt to(Construct)an Individual Sewage Disposal System. at No 326 FOREST STREET as shown on the application for Disposal Works Construction Permit No. BHP-2014;072.: -Dated August 01,2014 g, t ----- __ -___-___---------------------------------------- Issued On:Aug-01-2014 BOARD OF HEALTH 1p tion for tip i I System Construction Permit — T OF TODAY'S- DATE $250.00—Fu n Repair ANDOVER, 0145 NORTH $125.00 -Component Important: Application is hereby made far a permit to: When filling out a Construct 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 use the return A. Facility Information key. ------ ---- Address or Lot# City/Town 9t 1 A4070v—i 2.m*TYPE OF SEPTIC SYSTEM : ❑ Pump ❑Gravity(choose one) '***If pump system, attach co py of electrical permit to a pp lication* >, ❑Conventional System (pipe and stone system) l ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) > ❑ Pressure Distribution S.A.S.(No D-Box) > ❑ Pressure Dosed(D-Box Present)S.A.S. ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before®WC issuance) What is tlae Make? 6f%75at is the Model? 2. Owner Information 1 i iM_ 1), 1()l14 1)1 Name 3 Address(if different from above) mtowh / 11fk +i +' AAA City/Town State Zip Code Telephone Number 3. Installer Information aurr '-"a A)t yAk sip IZt( oii r Name Name of Company Address t ` ) ( tw City/Town State Zip Code f ) Y J,S I/ Telephone Number(Cell Phone#if possible please) 4. Designer Information tf (31 f,.0 �� 14AiA,ty,�1 ___ t�►t�'��'1 8 A'I/� Name Name of Company )A A 6 vr Address k& A A/ta City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 T©DAY'S DATE Construction Permit - TOWN OF $ 250.00—Full Repair NORTH ANDOVE& MA 01845 $125.00 -Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Bu j!!jj t: ❑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. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. Name Date Application Approved By: (Boar of Health Representative) Name Date Application Disapproved for the following reasons: For Office Ua2 Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Puin-p stem? If so,Attach copy of Electtical Permit Yes No 4. Reviewed approvallettei; all papeiwoik feceived? Yes No Missing.• 9 Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6. 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: -----����� yvzp�os6y (\�Jzcso"Iocpucyymccn) (L"mQme=r) Relative to the application nf And dated 6-�5./4(Installer"", name) Dated � 0 2101A" D understand the following obligations for management n1 this project: 2. As the installer, I am obligated to obtain all permits and Board of Health approved Ev�od �600uaitz performing any work . I must have the approved plans and the permit on site when any work is being done. 2. Ao the installer,I must call for any and all inspections. IE homeowner,contractor,project manager,ozany other person not associated with my company schedules an inspection and the system is not ready,then item three shall boapplicable. 3. As the installer,I am required to have the necessary work completed prior to the applicable inspections xo indicated below. I understand that requesting an inspection,without completion of the items in accordance with Tide 5 and the Board of Health kegulations may result in a$50.00 fine being levied against meand/o my compAny.` x. Bottom of Bed—GcncrxUv` 6isist6cOcut/1`� inspcctionunlsudzcrcisuzotu6zingnmO,vvhich should be done first. The installer must request the inspection but does not have tobcpresent. b. Final Construction Inspection—Engineer oucs/ first 6o dz6z inspection for elevations, ties, etc. As-built o[verbal(}K (or e-mail to: from the engineer ouoot 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 t du\uzcoLn function. cause pump onmz�uo . c. Final Grade—Installer 000at request inspection when all grading ie complete. IoscuDcz does not have to6uoo-aitc. 4. As the installer, I understand that only I may perform the work (o/h,r/hux simple exxamxiox)and I urn required to complete the kistallation of the system identified in the attached application for installation. I further understand that work done byothers unlicensed to install septic systems in North Andover can constitute reasons for denial of the s)�stem and/or revocation or suspension of my license to operate in the Town of North Andover, siV 12 b -,gificant fines to all persons involved are also - ossi le. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: w. Determination that the proper elevation of the excavation has been *w*rhv'i 6. Inspection of the sand and stone to be used. c Final inspection 6x Board ofHealth staff vrconsultant. 4( 7wx/alluti*w of tank, I7-]5o^4 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 121ans. No instructions by-the homeowner, general contractor, or any other persons shallabsolve me of this obligation. Undersigned Licensed Septic Installer: &o<,/ (Tuday`sUate) / 4L Commonwealth of Massachusetts Official �mt�y Permit No. 1fr�✓ Department of Fire Servi