HomeMy WebLinkAboutHealth Permit # 8/6/2009 ---
i Map-Block-Lot
,OR H Commonwealth of Massachusetts 5 0
0
1 8. 000
103.-0005----------
Board of Health Permit No
p North Andover BHP-2009
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' " a FEE
P.I.
$125.00
F.I. -----------------------
DISPOSAL WORKS CONSTRUCTION IT"
Permission is hereby granted Todd Bateson
to(Repair-D-Box&Outlet Tee)an Individual Sewage Disposal System.
at No 61 ESSEX STREET ----
as shown on the application for Disposal Works Construction Permit No. -BHP-2009 064 Dated August 06,2009-----
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° d
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Issued On:Aug-06-2009 Board of'Healtfi t,
, r
licatinnfe%r C
" Construction Permit TO—D A r—S BATE
TOWN OF
ORTH ANDOVER MA 01845 $ 250.00-Full Repair
C"us
$125.00 Compon nt
Important: I'll
lication is hereb made for a ermit to- 4
When filling out JI,7
4 1"4,
forms on the ct a new on-site sewage
computer,use 6�p_`"E]�Const=���e� disposal system*
only the tab key ❑ Repair or replace an existing on-site sewage disposal system*
to move your
cursor-do not 'pair or replace an existing system component What?
use the return
key. A. Facility Information
VQAddress or�Lot#
reran 44
city/Town
2.-*TYPE OF WEPTIC SYSTEM*:
❑ Pump cavity(choose one)
***If Pump system, attach copy of electrical permit to application***
D-t-onventional System (pipe and stone system)
❑❑ infiltrator or Biodiffuser(Gravel-Less) (Attach a COPY of your certification to install this type of sste
y
Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement
El Pressure Dosed (D-Box Present) S.A.S. )
2. Ow
1!1qe_r Information
ddress(if different from above) - --
16'
'-s
(5ft—YrFown State
-
Zip Code
3. Installer Information Telephone Number
Name
Name ofCompany
Address
X?
_&_y1o,n
Zip
,
_ ' ode
Telep I on e Number(Cell Ph one#if Passi
bie—please)4. Pesigner Infor atio
Name
Name of Conpary ---
Address
City/T own
State Zip Code
Telephone Number—(Be—s,—#Io Reach)
Application for Disposal System Construction Permit Page I of 2
pp hrH l i ti n f r ti i i t --- As �S DATE ,
n tr ti Permit - TOWN T
4
ORTH $ 250.00® Full Repair
ANDOVER. MA 01845 $125.00 - Component
sACHUSE
PAGE 2 F
A. Facility Information continued....
�,� yMm
5. Type of Building: E2Ke°°sidential 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 in operation until a Certificate of Compliance has
,
been issued his Board of Health.
Name. Date
i
Application pproved By Board of Health Representative)
Na Td' Date
N=�A'pplication Disapproved for the following reasons:
For Office Use Only:
Z Fee Attached. YesJ No
2. Project Manager Obligation Form Attached? Yes No
3. Pump S sy tem? If so,Attach cop=y of Electrical Permit Yes No
4. Foundation As-Built. (new construction ronly): Yes No
(Same scale as approved plan)
5. 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:
(Address of septic system) For plans by
n eer)
Relative to the application of e ✓ /J/,1n
(Installer's name) And dated
rl at ate
Dated — Lj ,
(today's ate With revisions date
(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 (1 ) 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: healthdept ntownofnorthandover.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 Health 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)
(Name— not ame— e