HomeMy WebLinkAboutHealth Permit # 4/27/2011 ®r GRTk � Commonwealth of Massachusetts Map-Block-Lot
3r •" ° 107.60109
BOARD OF HEALTH Permit No
North Andover BHP-2011-0597
P.I. -----------------------
1� FEE
cwu0, F.I. $250.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Mike Reilly
---- --------- ------- -------- -----------------
to(Repair)an Individual Sewage Disposal System.
at No 215 OLD CART WAY
as shown on the application for Disposal Works Construction Permit No. BHP 2011-059 = Dated
f
____._____._.__•-----------------------------------------------
Issued On:Apr-27-2011 BOARD OF HEALTH
r
AApWi6ation for Sg2g i y j Ll
my . n tructi Permit — TOWN F TODAY'S DATE
„ � $250.00—Fun Repair
� 01845
„ A $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 p y
computer,use epair 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
use
y Facility the return
key. Information
Add s or Lot# - -
—
_ ..
City/Town
2.-*TYPE OF EPTIC SYSTEM*:
❑ Pump Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Co mentional System (pipe and stone system)
filtrator or 13iodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
Name —
Address(if different from a ve ar ) -
—
y Tw State - Z
Cit In� ' � � -
Code
Telephone Number
3. Installer Inform"ation
Name` -
,ow Company
Andress - - -
City/Town State Zip Code
(
Telephone Number C
p el!Phone#if passi le lease)
. _
4. Designer Information „
Name Name of Company
Address
City/Town State Zip Code
Telephone Number #t
p (Best a Reach)
Application for Disposal System Construction Permit*Page 1 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:
(.��id7xti>.,aWd rsP,��E�vr�. ti,��F;eR�rrl) For plans by ��s
Relative to the application of "),
(h o tflcr's x�r,r
lnd dated
Dated
With revisions dated
(Last rc6sed(kV tc)
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 in�ior to
performing any work on a site. I must have the approved ved 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 atn required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requestin ag n inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally, this is the first (1") inspection unless there is a retaining wall,wlvch
should be done first. 7$e 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 OI4 (or e-mail to: lac t➢� a ,, iru(tl_i_a ��,a a,�i�i,� ,iia_�i�?<� . r�„dot i) 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 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.
G. As the installer,I understand that I am solely responsible for the installation of the system as per the
approved lan5 No instructions by the homeowner,general contractor,or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: fier) � � ��t) (.t`eaa.ls)y's Dat")
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