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HomeMy WebLinkAboutHealth Permit # 5/11/2016 Commonwealth of Massachusetts Map-Block-Lot 107.60146 BOARD OF HEALTH Permit No North Andover -------------------BHP-2016-0151---- P•I• FEE F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John DiVincenzo------------------------------------------------------------------------------------ to(Repair)an Individual Sewage Disposal System. at No 30 OXBOW CIRCLE __- as shown on the application for Disposal Works Construction Permit No. _13HP-2-01-6-9-1-5. Dated May 11,2016-------- - ---------------------------------------------------------------- Issued On:May-11-2016 BOARD OF HEALTH ---------------------------------------------------------------------------------- on for tic i i Y - - ' Construction Permit - T F TODAY S DATE $350.00-Full Repair NORTH ANDOVER, MA 1 $175.00®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 ❑ Repair or replace an existing on-site sewage disposal system* only the tab key repair or replace an existing system component®What? to move your cursor-do not — r use the return A.. Facility Information key. ----------------- rya Address or Lot# -- — I ° ° City/Town 2.-*TYPE OF SEPTit, SYSTEM*.- I`iAY 1 � �01 ** � E] Pump ravity(choose one) `th� G �14'°VI��C"I[iINIII` W°.fl' If pump sy tem, attach copy of electrical permit to application }� ®91onventional System (pipe and stone system) Y ❑ 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 DWC issuance) W/liat is the Make? Wt%liat is the Model. 2. Owner Information Name - Address(if different from a ove) City/Town State Zip Code Email address Telephone Number 3. Installer Information m . --- .. I Name ! to Name of Company — Addres City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Application for Sqptic QisgQ§AI System ---—----------------------------- Construction Permit — TOWN OF TODAY'S DATE $350.00-Full Repair NORTH ANDOVER, 01845 $175.00-Component PAGE 2 OF A. Facilitv Information continued.... 5. Type of uildin-g: Residential Dwelling or FICommercial 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 Environme tal code, as well as the Local Subsurface Disposal Regulations for the Town of North n Tier, un s�an li'at until a final Certificate of compliance has been issued by this oa of alth t e tailed system is not approved. Date Application Approved By>'(Board of Health Representative) Name Date Application disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Forni Attaclieda Yes No 3. Pump S, sy tern? Ifso,Attach copy ofElectrical Permit Yes No Applicant received copy of "Elecu calIiispection Notes for Septic Syste-ms" Yes No Handout? 4. Reviewed approvallettef, all paparworkreceived? Yes No Missing. 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) G, 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 s�'st:etn) For plans by � (Engineer) Relative to the application of �� (Instafler's name) And dated 11gif'1a date) Dated I'D /// / 5 oday s 4 ate:) With revisions elated (l...awt revised data:) I understand the following obligations for management of this project: I. As the installer, I am obligated to obtain all permits and Board of Health approved plans pilLo r 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 (1s) 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: heallt.�idq-)ti 4)trr\�7tiofri ortl.rancicwer.c(�iii) frorn 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 putnp 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 thalr simple e caiwtiew)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 trust 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 ofHealth 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 121ans. No instructions by the homeowner, general contractor, or an other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: ' � (Today'W 17ate), 0 a.ine .... Tint: I I i rTcw`.._ 5igne:c.