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Home My WebLink AboutHealth Permit # 7/24/2012 jLVD, Commonwealth of Massachusetts Map-Block-Lot 106.00086 ----- --------------- BOARD OF HEALTH Perm it No 94 -06 -201 HP B North Andover -----------------------2 BHP 2-06 P.I. FEE F.I. $125.00 DISPOSAL WORKS CONSTRUCTION I'T Permission is hereby granted warren Pearce Jr. to(Repair-D-BOX;MAIN LINE;INLET TEE)an Individual Sewage Disposal System. at No 105 CARLTON LANE as shown on the application for Disposal Works Construction Permit No. 13HP-2012 7069 Dated July 24,2012 ------ - ---------------- Issued On: Jul-24-2012 ..._ -BOARD OF HEALTH r ' f A ." TODAY'S DATE Construction it — TOWN OF�1 $250.00-Pull Repair $125.00 -Component Important: Application is hereby made fora 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 use the return key. Facility Information A. rib Address or Lot# J-6/ /Town -- — — — I t enan y — - °i1 dND.i yI f � ro ""f 2.- *TYPE !�F SEPTIC SYS°TENI*: t�aAl,.°��t at�, u� r ❑ 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 -- Name ------- - --------— ----- --- - - --- - -- Address(if different from above) - - - - City/Town State + Zi Code Telephone Number 3. Installer Information Name of Company Na---tet�m Address f� -- ---- , - - City/Town r State Zip Code t l T lephone 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 m 7A TODAY'S DATE--- Construction Permit — TOWN OF µ 01845 $250.00-Full Repair � �. $ 25.00 -Component PAGE 2F2 A. acility Information continued.... 5. Type of uilding: tesidential 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 is ued by this Boar of Health. mm Name Date A pp Ilcation� r Qua�d . �". (Beard of Health ?e p resent ativ " ----------- - - — Name Date Application Disapproved for the following reasons: For Office Use PnIV. 1. Fee Attached? Yes "" No 2. Project Manager ObEgation Form Attached? Yes " " No 3. Pump System? If so,Attach copy ofElectrical Permit Yeses No 4 Foundation As-Built?(new construction ronly): Ye / No (.dame 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: (1Wdrf s 4'skp6( .,ys(E°w) For plans by Relative to the application of )r (w�Mc ry And dated Dated aac d} �c 1 With revisions dated (1'mo Glaw) 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 Pdor 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 ant 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. Bottoin 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 OK(or e-mail to: , 4 bC€,i,i(,ti i�.1(,i,(�,� � 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 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 roust 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 ebamber, 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 obli ag tion. Undersigned Licensed Septic Installer: " (T'�n�lsu(�'s i"�:uQc . , Commonwealth of Massachusetts ' T°N t0 e 5 Offi 0"a N Inspection Form |� Subsurface Sewage DimAnsaYSysbmmmF#rnm -NmtforVo|untaryAsaemementa 105 CARLTON LANE NORTH ANDOVER, MA 01845 Property Address M|CHAS. BARNUM Owner Owner's Name information i's required for NORTH ANDOVER MA 01845 -JULY 2O12 � -____- ____----_ � every page, City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes /conL>: Z Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(e) or a broken. settled or distribution box. �ymbamv�U ' | pass inspection ifkwdh approval Vf Board VfHeoKh>: El broken pipe(s) one replaced n Y F1 N Fl ND (Explain below): || obstruction iGremoved n Y El N Fl NO (Explain he|ovv : D� distribution box ks leveled nrreplaced M Y Fl N Fj ND (Explain below): DISTRIBUTION BOX CORRODED-RECOMMEND REPLACEMENT. MAIN LINE GOING INTO � SEPTIC TANK |S BREACHED- FLOW ENTERING NEAR G/DEVVALLDF TANK AND NOT THROUGH LINE AND INLET TEE. RECOMMEND REPA|R/REPLACEKAENTOF CAST IRON MAIN LINE AND RECONNECTION OF INLET TEE El The system required pumping more than 4 times a year clue to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): El broken pipe(e) are nep|mood n Y n N El ND (Explain below): n obstruction in removed El y El N E] ND (Explain below): ' � C1 Further Evaluation imRequired bv the Board mfHealth: L] Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public heo|th, safety orthe environment, 1. System will pass unless Board mf Health determines in accordance with 31DCKAFi 1S.3O3(1)(b)that the system is not functioning |nm manner which will protect public health, safety and the environment: �l Cesspool � �� Fl Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh mm"'11/10 Title o Official Inspection Form:Subsurface a"=agemspo"/nptem'pao°oofn