HomeMy WebLinkAboutHealth Permit # 8/11/2015 X11" D Commonwealth of Massachusetts Map-Block-Lot
107.D0112
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BOARD OF HEALTH Permit No
BHP-2015-0250
North Andover -----------------------
P.I. FEE
F.I. $250.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted -Todd-Bateson-----------------------------------------------------------------------------------------
to(Upgrade)an Individual Sewage Disposal System.
at No 217 GRAY STREET j
- ----------------------------------------------------------------- - ---- --- ----- --- -----------------------------
.4T*
as shown on the application for Disposal Works Construction Permit No 2 ------------
V
'I tion for a tl Disposal I W ( � A
TODAY'S DATE
I& $n tructi Permit - TOWN OF
NORTH ANDOVER, hU 01845 250'.00'®Full Repair
$125.00-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 epair or replace an existing on-site sewage disposal system*1�
only the tab key r
to move your El Repair or replace an existing system component—What?
cursor-do not /I Y
use the return A. Facility Information
r`fi�ft
,,w
key. �, �� .,. .. l`()10"i
Address or Lot#
VQ
Cityfrown - ---- {
2.-*TYPE OF SEPTIC SYSTEM
ump ❑Gravity(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 your certification to install this type of system.)
> ❑ Pressure Distribution S.A.S.(No D-Box)
➢ ❑ Pressure Dosed(D-Box Present)S.A.S.
p ❑ 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 DINC issuance)
Who tis the Make? What is the Mod N'
2. Owner Information
Name
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
1
Name Name of ComPa °'T C N NTEP:,nE'r>r,,, INC.
Address
City/Town State Zip Code
'V Y J
Telephone Number(Cell Phone#if possible please)
4. ®esioner Information
Name Name of Company
Address
Ab
—
Cityfrown - State Zip Code
Telephone Number(Best#to Reach) -
Application for Disposal System Construction Permit•Page 1 of 2
gad"tit 5 ..
to Cl tr ti I� rooArs DATE
ORTH $.250.00,Full Repair
" ACHUS $125.00-Component
PAGE 2 F
A. acllit r,Information continued,...
S. TYpe'of Building; a is dential Dwelling or Commercial
B. Agreement
The underslgned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system In accordance with the provisions of Title S of the
Environmental Code, 'as well as the Local Subsurface,
ubsurface Disposal Regulations for the Town of
North Andover, and not to place the system In operation until a Certificate of Compliance has
been Issued this Board of Health.
Name
Date
Application A raved . .�
pp y ,,ar ..ot Health Representative)
,Nam� Clate ' rry .
Application Clisapproved.for the following reasons.
For ®flee Use Only°
1 '.Fee Attached? Yes Na
2.• Ptojectllf"-"get Ohygatron Ford Attacbeed? Yes No I
3°: EMA4WCM,a Ifs 0)Attach cdpy ofL'lertrr'rd petrrrk. NO
4. FoundatronAs Buatt?(new construction-ronly),, I'es®
(Same scale as a ro ed lair Ns
FF F .
A Floo.-R r s?(new construction only). Yes
No
Appifrat(on fiar plspgsal Syst�rih: ®nstructioh Permn>Page 2 Of 2
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