HomeMy WebLinkAboutHealth Permit # 5/2/2016 i
• k LED, Commonwealth of Massachusetts Map-Block-Lot
096.00066
BOARD OF HEALTH
• Permit No
' I
North Andover BHP-2016-0103
FEE
$175.00
DISPOSAL WORKS CONSTRUCTION IT"
Permission is hereby granted Todd Bateson
to(Repair)an Individual Sewage Disposal System.
at No 371 STEVENS_STREET--------_
as shown on the application for Disposal Works Constriction Permit No. BHP-2016-010 Dated May 02,2016
----------------------- - ------------------
Issued On:May-02-2016
BOARD OF HEALTH
tion for So tic Dis l ystem, k/.. d fig----/4""',
T(7DAY'S DATE
Cons tru tl n1 Permit — TOWN OF
250'.00'—Full Repair
NORTH ANDOVER MA 01845
00-Component
Important: Application is hereby made for a permit to;
When filling out n Construct a new on-site sewage disposal system* r'0
forms hsewage ��i�"�!
computer,use ❑Repair or re place an existing on-site dis disposal
�1VL)()
only the tab key @ "� z��I ):F���) f�C�. {rr"�'
to move your 61 Repair or replace an existing system component—What.
cursor-do not
use the return A. Facility Information
key. -511
Address or Lot#
K
City/Town
2e-*TYPE OF SEPTIC SYSTEM
9 ❑ Pump ®' ravity(choose one)
—*If pump system, attach copy of electrical permit to application-
> �Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of yourcertifieafion to install this type ofsystem.)
> ❑ Pressure Distribution S.A.S.(No D-Box)
9 ❑ 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 DIMC issuance)
What is the Make? What is the Mo&L
2. Owner Information
IV _._;
Name
Address(if different from above) B wµ
.. l�,.
City/Town State Code
Zip
Telephone Number
3. Installer Information
em..
f Name of Comp t 11 fOIC,@0_i
Name � � �. 1fV��
d
Address
Zi
Cityf town State p Code
9�
Telephone Number(Cell Phone#if possible please)
4. �esiigner Informattion
EAddress Name of Company
w State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
,RTH Applieati'on..for Septic Disp.®sal S stem J-1-j o
• d
.,"''•.tie •..•. .
3=.�+ �.• °c TODAYS DATE
A Construction 'Permit = TO N• OF
* ' ' '•'y* •ORTH ANDOVE M:A 01845 $:2500 -Pali Repair
� $h25..00-Component
iSSACHUS
PAGE 2 OF 2
A. Facility.Information continued.,..
5. Type-of Buildin : Residential Dwelling or(]Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system In accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system 6 operation until a Certificate of Compliance has
been Issue W,this Board of Health.
Name Date
Appiic ppr ed : ( and o ealth Representative) l
Name Date
Appl ation D sapproved,for the following reasons:
For Offide Use Only:
1 "Fee Attached?: Yes No
2,• Ptojecf atiaget Obligation Form Attaebed? Yes No
3,; LW-j vstem, Ifsoi Attach cwpy ofElectrical Petmit'.•i 'es No
4 FoundadonAs B• ' (hew construction-ronly); Yes_ No
(Same scale Ogg Toyed plan)
A. FloorPlans?(hew corisfru ion-only): Y.es_ No
Applfcxtion'fior�plspp5al yst6' 10onstructlon Perna ROge 2 of 2
sErtlC* t -nqV F" MAX&qM �''�(38LiGd�IQi�TS
As flWNqiffiAudaver,ltcwsed4iiftHexfrs�##4t tbtntc tt'fda he�epticayatef c .the�pre�pextFst:
(Ad4stu of updc Wstuss) -Act pUm by
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(iia� r some AM dated
tu
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DOW a
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Whit irddotts dated
{I t 'sed date)
I undesatatad the following boligotions for management ofahis project
1. .A As.the iasb&4,I az2as.obligated its obta&aU pe=ns and Bpstrd aMesdth i pprovad pkm pda
�petlioniag aap:work da a eite:.I mQSt hm*gUV=32agWji a24 tht,pc jm t-on aft Rio M jFA$fa
2. As tk inbb ter;,I.miistS U-for any and idI'ipspwdom I£ho42eamm4 contract("projectnsmga or scay
o*erpt nca not mi4oc h ted with my empiay mAmUm•an ittapectiott tad the sysbcpn is notmc 6 theft
hem atzea•alla bliss pltcable.
Ae x .itq ?ed fio bav+ee a►ot�ed:ptia to the,appllgtb?e iapectigs as
indiscds. ..
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moo
# ►I�t t iiaspGCdoft�a dges•dot have to b4 presai:•
b, t�' t ueefttt>at6tx ila tcit`j4gi on tot devablIs;ft etc.
t Q 't►Gt47u t✓11`�.e: ll to y {1`0231 t�iC eti&eer must
ba itibmited tri Hosxd'of Ham, `� for Rif iecttl tune.'Iatsmllar"t
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4. Aslhe iAatalies,'I t;niirg 'and that only h g ¢te val k'(ot6ir"�im�,(a wwwIff ind•I atns•foq*ed
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