HomeMy WebLinkAboutHealth Permit # 5/2/2016 1:EI,, e Commonwealth of Massachusetts Map-Block-Lot
107.D0097
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BOARD OF HEALTH PennitNo
North Andover BHP-2016-0104
P.I. FEE
F.I. $175.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd_Bateson
to(Repair)an Individual Sewage Disposal System.
at No PADDOCK LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2016 7010 Dated May 02,-2016
Issued On:May-02-2016 BOARD OF HEALTH
TODAY'S DATE
i Permit
$250e00—Full Repair
NORTH ANDOVER, 01845 $1,25. Component
Important: Application is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal system"
forms on the
computer,use El Repair or replace an existing on-site sewage disposal s�to 0W 9 iP I'�dE�I" I f P SI"117�)��t„IRS
only the tab key p g g p Y m*
to move your Repair or replace an existing system component—What.
cursor- et not
y Information
kee the return A. SDIIIh/ Inforrrl�
Address or Lot#
-dilyfrown d .,....._.._
2.m*TYPE OF SEP'T'IC-SYSTEM*:
> ® Pump D ravity(choose one)
* if pump s item;attach copy of electrical permit to application `°
➢ [?Conventional System (pipe and stone system)
> ❑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 L)WC issuance)
Whhatis die Make? What is the M'od ffl,
z. Owner lnf®rmtion N�7Ar�,,.,�._
Name
rr
Address(if different from above) 24
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of 0,00 N 177,IN j I r:i 3pr,11,,L ,IN0,
Address vA
City/Town State Zip Code
Telephone Number(Cell Phone#lf possible please)
4. esLpner Infor tion
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit o Page 1 of 2
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