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Home My WebLink AboutHealth Permit # 4/28/2010 Commonwealth of Massachusetts Map-Block-Lot Qe aqQ 107.A0203 p ---------------------- g L Board of Health Permit No A North Andover BHP-2010-0560 P.I. FEE F.I. $125.00 DISPOSAL WORKS CONSTRUCTION IT Permission is hereby granted John-DiVincenzo to(H-20 D-BOX REPLACEMENT)an Individual Sewage Disposal System. at No 224 CARLTON LANE as shown on the application for Disposal Works Construction Permit No. BHP-2010 05,6 Dated April-28,2010------- ----- --------- Issued On:Apr-28-2010 Board of Health t � a e� Application for ae w a' Construction TOWN Permit — F TODAY' DATE $ Full Repair ORTH ANDOVER, MA w � 0184 .w, 5.00..,® ornp neat......, JA 7 Important: Application is hereby made for a permit to: I� I When filling out forms on the F-1 Construct a new on-site sewage disposal system* computer,use ❑ Repair or replace an existing on-site sewage disposal sys etri* only the tab key to move your Repair or replace an existing system component—What. cursor-do not use the return „ key. Facility raA Address or Lots „,,., F 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 I Ply 8 �ca tC Name Address(if different from abo e) City/Town State Zip Code Telephone Number 3. Installer Information -, Name / Name of Company Addres a City/Town State .. ip 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 >, � ilic tr 4�t t1 n for r stem m it - TOWN OF TODAY'S DATE $ 250.00®Fu ll Repair $125.00-Component PAGE 2 OF A. Facility Information continued.... 5. Type of Building: WResidential 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 by this Board of Wealth. ` 6 Name Date Applic tjoln Approved ,,"Board of Wealth Representative) Via:" Date Application Disapproved for the following reasons: For Office Use only: Z Fee Attached? Yes k"" No 2. Project Manag-er ObEgation Form Attached? Yes Na 3. Pump s sY tem? If so,Attach coQE ofElectrtcal 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: (.1cldi ss of sepoc system) For plans by Relative to the application of t) J j � ) Q,fl ZZ) (In,,aller's name) And dated rt¢.,t to date) Dated d � l ��E xy-�;��, With revisions dated ('1.„kst rctvdse<I 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 pAor 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 OIL (or e-mail to: lscatliclet ca,)towioftiorth,,i�dor71.c on ) 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 single excaw ion)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 overate 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 tanlr, 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. Undersi ned Licensed Septic Installer: ("l'crcicty's Dat ::imc: .... nt-) : a e .._ 4 4,11u c. 77 TOWN OF NORT`LI A DON7ER. o p1OR7'H q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENTa A 1600 OSGOOD STREET;Building 2-36 ' QDgnCIH nna`Y NORTH ANDOVER, MASSACHUSETTS 01.845 �s5gcwua�K� Susan Y, Sawyer,REHS/RS OVER MA �° �� ,� o �', � "� ' "�, ,��,� ,� � ,� �, �.� 978,68.9540—Phone Public Health Director .. �' &688.8476 F. D-BOX � w. Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) � Hydraulic cement� ��'°, ❑ , � y around inlet & outlets Observed even distribution Comme nts: Speed levelers provided (not required) �' `.� SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 '/a" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices a(-7 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater Systern Documentation—Feb 2006 Page 3 of 6