HomeMy WebLinkAboutHealth Permit # 5/28/2013 ...........
• 4�"�Ti",J � c,.e Commonwealth of Massachusetts Map-Block-Lot
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® 107.A0208
BOARD OF HEALTH - r --
® Permit No
North Andover BHP-2013-0728
P.1.
-----------------------
FEE
F.1. $250.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted James Kellett
to(Construct)an Individual Sewage Disposal System.
at No 213 CARLTON LANE
— ---- ----- -------- -------- ------- — ---- --
as shown on the application for Disposal Works Construction Permit No. 1311P-2013-072 -Dated
___ _ -�+ t _�__� _� 3_`_____________
_____
Printed On:May-28-2013 BOARD OF HEALTH
Y
94 MoRrw Application for IC Dis osal System MAY 23,2013 _
o � TODAY'S DATE
Construction Permit - TOWN OF
A 4 $ 250.00-Full Repair
a
r1SSacwv��K $125.00 -Component
Important: g p y
Application is hereby made for a permit to
When fining out ❑ Construct a new on-site sewage disposal system* ��
forms on the m
computer,use FOR Repair or replace an existing on-site sewage disposal syste '*
only the tab key
to move your ❑ Repair or replace an existing system component—What?
cursor-do not
use the return
key. A. Facility Information Infti (C)Vvt
213 CARLTON LANE
sae Address or Lot#
NORTH ANDOVER
mean City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑ 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) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
DAVID FOWLER
Name
213 CARLTON LANE
Address(if different from above)
SAME
City/Town State Zip Code
Telephone Number
------------------------------------------------ --
3. Installer Information
JAMES KELLETT KELLETT EXCAVATING LLC
Name Name of Company
400 SALEM STREET
Address
LYNNFIELD MA 01940
City/Town State Zip Code
781-953-7146
Telephone Number(Cell Phone#if possible please)
4. Designer Information
LUKE ROY LJR ENGINEERING
Name Name of Company
234 PARK STREET
Address
NORTH READING MA 01864
City/Town State Zip Code
978-664-8141
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
Application for Septic Disposal System MAY 23, 2013
a $Construction Permit — TOWN O TODAY'S DATE
ORTH ANDOVER, MA 01845 $ 250.00—Full Repair
$125.00 -Component
wtaous�
213 CARLTON LANE
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: Residential Dwelling or OCommercial
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 sued by this Board of Health.
am Date
--------------
Applicati Approved By- (Board of Health Representative)
r
Nam Date
App cation Disap roved r the following reasons:
For Office Use Only:
1. Fee Attached. Yes No
2, Project Manager Oblig anon Form Attached? Yes No
J. Puna-S,,stern? If so, Attach coply of Electrical Permit Yes N�
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as a-proved plan)
5. Floor Plans?(new construction only): Yes_ No
Application for Disposal System Construction Permit-Page 2 of 2
SEPTIC SYSTEM INSTALI-,ER PRO,(ECI' NIANAGENiENT OBLIGA'T'IONS
As the North Andaiver licensed installer for the timsIruction for the septic system Ior the pruperty at:
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f
t'rN l 1' r 1'
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ld<src,,�il,�l iEe ststcin � l;lns ? --
il�,ni;aiuct;
Relative to the application of
And dared 7
In'+1tllc+' ��atiicr P �'? ! 0` �
1
Dared �, f��
AC'ith revisions d:ued
�I.d�t rrri.cil�l,ur�
I understand the following obligations for management of this project:
1. As the installer, I am obligated co obtain all hermits and Board of I I"hh apprtwo d plans Prier to
performing;any work oil a site. I must have thwpRRwcd plans and the hermit r>n site \\�Jhen any work is
b6ng done.
2. As the installer, I must call for any and all inspections. If homeowner, connrackw, pn je"c.t matmTer,or any
other person not associated Saida nay company schedules an inspection ,uid the system is not ready, then
item three shall be applicable. I 1 11 I
3. As the installer, 1 am rce erred to have the necessary week com Meted prior to the applicable>lic able. ins cctions as
indicated bclrnv. 1 understand that r e [ig in,*) ion, without co �letc �1 u m n _heics in cco anecn c roa
with Title 5 and the Board of Health Regulations naafi result in a WUU tine beine"lcv ied ophnst me ,and/or
my company.
a. Bottom of lied ---Ckncralll', this is the first (1") inspection unless there is a retaining_; wall, "Vich
shoWd be done first. The installer must rcqucst the inspection but does not- have to be present.
b. Final Cgnstrt�ctton Inspection —I?ngincer must First do their inspection for elevations, tic., etc.
As-built of verbal M' (or c-mail to: Ili tliV�tl �t�t,.�.»�_t�e.�t,7z�rthan<a;_,�°�r c�:�rar) from the engineer mutt
be submitted to the Board of health, after which installer calls for an inspection time. Instatllcr must
be present for this inspection. With a pump sestem, all electrical wA-k must be ready and able to
cause Purnp to wort: and .darn-i to function.
c. Final Grade -- Installer mast request inspection when all grading;is "nnplete. Lastallcr does not
have to be on-site.
4. As the installer, I understand than only I nuy perform ill(- work (n/bel-lbtrrr simple and I am required
to complete the installation WIN system idenriticd in ncc attached application for installation. I titrthcr
Understand that work clone b others unli�c r7sed to install s,c�tic systems in North Andovcr can constitute
reasons for denial of the system ,and/or nA-twa6on or sus Tension of my license too crate in the 'Town of
North .1n�Irn� r st�;nilteant hers to all pers�ms invc�hcd ,ire also po„iblc.
5. As the installer, I understand that 1 mum be on Ate duw-ing the per6wmance of the following cunsrruction
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.
(. .1s the instiller, I undersr'utd Char 1 am solely reslaonsiblc f<>r the installation of the sl ac:m as pc'r t:he
approved plan, No instructions ha tlac hotne���e�tar�r. perteral eonlraejor, rx am' other persons shall absol�
I of this obligation.
Lndcrsi>;ncd Licensed Septic Installer: 0�,
Tin i'tltt