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Home My WebLink AboutHealth Permit # 11/17/2015 Map-Block-Lot Commonwealth of Massachusetts 109.00029 ----------------------- BOARD OF HEALTH Permit No North Andover -BHP-2015-0908 08 --------------- -- P.I. FEE F.1. $250.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted _Jay_Wadsworth--------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No --7-0-0-MIDDLETON-STREET as shown on the application for Disposal Works Construction Permit No. BB-P-2-0-1-57-090--- Dated --November 17,_2015 - ---------------------------------------------------------------- Issued On:Nov-17-2015 BOARD OF HEALTH - ------------------------------------------------------------------------------- LIi tin for TODAY'S ATE Construction Permit — TOWN OF NORTH ANDOVER, 0184 $M._0o, Fuji Repair 'i :�® -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 to move your ❑ Repair or replace an existing system component®What? cursor-do not key. m Lion , use the return Facility for p� ..,, 41 t Address or Lot# r F� - - --------- City/Town °rte 2.-*TYPE OF SEPTIC Y 1° NI*: -- Y ❑ Pump ff 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. )�, ❑ 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 OWC issuance) What is the Make? Wha t is the Model? 2. Ow er Information - Na e Address(if different from above) City/Town State t✓��,V ,ZC5(14" Email address Telephone Number Installer Inforrnation _ 3. ns — ------ -------- Name Name of Company tt A_r etc Addre s "\ City/Town State l� ,„, �Z-,p Code Telephone Number(Cell Phone#if possible please) 4. Deslaner Information w --- tame of I Company „ i (I ( A k �, Addr ss City�/1 own Sta#e Zip+ Code Telephone Nu ber(Best#to Reach'°- Application for Disposal System Construction Permit Page 1 of 2 4..1 , tin for S osal Xstem instruction Permit — T F TODAY'S DATE NORTH 01845 z5a.a Full repair ""��-25':da -Component PAGE 2OF2 A. Facility Information continued.... 5. Type Of BuLigi rA: eResidential 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. 1 understand that until a final Certificate of Compliance has been issued by thi Boar 'of Meal h, the instal a .ssm is not approved.l /I N m' Date Ic�ati n A rove CW ' pp Y. oard Health Representative) Name ' Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No Z. Project Manager Obligation Form Attached? Yes No 3. Pump S s� tem? If so,Attach copy of Electrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all papercvoA creceived? Yes No Missing' 5. Foundation As-Built?(new construction only); Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INS'T'ALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: . (.�a{r814�ss of septic s}�ste�1II�r) For plans'k.� .' k �Ym,ls 1Y°alII"2t'.4 k Relative to the application of llco t n.tasar.,) And dated c� � (0figmal Oat(') Dated With revisions dated (La";t r e�'ised c gate) 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 c0mpan a. Bottom of Bed—Generally, this is the first (141) 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 OTC (or e-mail to: ht alt,R,dC.,..)g_�e�>,f�reyr s;t r��t�_f8; tknd< wr _a�,t 1) from the engineer. must be submitted to the Board of Health,after which installer calls for an inspection tune. 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 evcavation)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: II ("Today's'F)"Ite) KK. 1��,.,�,!+ l'�.:��•�v.�v rV u, 1�u�.,.v.,owv, 'dil � .� ; {,"y{,„;Y�1 " uv, .t a y,�V•,V�5,wV✓/;:rV"{t v L�,'IlJy.;.V;J�.IV Ui l,Iv U,.i}v J/..l v UI I.t,��J I1Iv„J hA,V J''llV rw,f ll t v/,',jV Je A lA{VUl 1(,V u A,rtv�l,l ll'rsil),i.c,.l1 l.u,I,t.'i/I.t s_"i-i I/, 'i;'s.r Y V V V i )) 'v'v�v......�'v•...r�'v'...'.✓tuJvL..�'v....'v',�v+:`vv ��t�� r _ r x 1 • , c r a 3 t �i'��`�`,I�J) <<<-��`��..x "'tai•. ��.r1/1+'�/"\I�.1r►/'4I�1 rYI1I1 '1�Iti/1/'\/r1•'1�1f41"\r1F'�Jti lti rl/'Y I1/tiM�� \�.t11i r'' / f E LI{,linl RI n l In 1 1 I'i F,/ 1 11n Int'.'•n.•r••.In�,n In n rn.h In..-•.-.In.r�.n .....1..-.r.•+..+.r. ..�.....�a......-.nrr.C.>c SO I, 7,,31'1 11{lllli!1 I I t vj, )4� �� 4 } M'd } �. ;i7 T � KJ♦4�f Mll l• ;a �- �- .Z Y'• �� , g4'ft hL� � X1'1+�' tt�� `t�' �Yl;f�,'rJt ia�ti ��,`'; 3 t'y � �1�.�1 ��'� � �7�L` �. �t � 111 .+• y � ,+ .tf,. �t �..t M t� �S1 � i y rC' /., ti''t•Y+c'• }tat!<{'F t-'t\'1C'•v ;, t�,t tt^'� 'c� tA.�• i��{� / i+.: /y�i� Ilja +. �r �•� `r�. �r.M1�,i a,l t •I((``+++..{{{{1.1�,I�#.4�-t i.�}}t�'.t `�t 1{� `��F t�f 7 t?x hT 1r{ 1 ....fr y1l \` �),` � t �N' ( :�i\ � r a1 t�l tr ��Y,:yV- :�l ...�':. 'I�.l r•, .�,+..� 1}Y S .�+.} � -r�`�� at�r�'1' �f\•.r?��f �t xa�.tAA r�t'�r 't ��< ��`�t S -}.t,. t�?tA S��{ ;�;;n,(r.�9. This is to certify that Jay C. Wadsworth North East Classic Engineering Has satisfactorily completed a R = +1" PREMM RMT Series Installation Seminar And is now part of the Certified Roth MultiTank Installer Network 12-22-2015 22395 DATE OF CERTIFICATION RMT CERTIFIED INSTALLER NUMBER ProSource MANUFACTURER'S REPRESENTATIVE Rt4i OBAL PLASTICS OFFICIAL ! -December 10,2015 Jay Wadsworth North East Classic Engineering 6A Knox Trail Acton, MA 01720 VIA U.S. MAIL Dear Jay: congratulationst You successfully compteted the CULTEC Chamber Septic Installation Ccrtification on December 10.,2015. Your certification number is: MAC.I 20915-WAD please fv-.l fTep,to contact us regarding ourproducts and propor installation. Thank You for choosing CULTEC. Respecti-1111Y Y010. *Li. Lyneh _�P Customer Service Represelitative YM CULTEC, Inc. 978 Federal Road 9 P.O. Box 260 a Brookfield, C�06804 Phone,203-775-4416 Toll Free:800-4-CU�TEC - Fax: 203-775-1462 -Web-www.cultec.com CULTEC |