HomeMy WebLinkAboutHealth Permit # 10/9/2012 ® Commonwealth of Massachusetts Map-Block-Lot
• 106.60138
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BOARD OF HEALTH Permit No
North Andover BHP-2012-0730
P.I. FEE
F.I. $125.00
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Todd Bateson
to(Construct)an Individual Sewage Disposal System.
at No 95 OLYMPIC LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2012-073 Dated.--October_09,-2012
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Issued On: Oct-09-2012 BOARD OF HEALTH
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a° a°�° �� ol.��t1rtt117 It
�250.00—Full Repair
845 $125.00®Compcnent
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important: Application is'hereby made for a permit to:
when fiigng out ®Construct a new on-site sewage disposal system*
forms on the
computer,use ® Repair or replace an existing on-site sewage disposal system*
to move our y epair or replace an existing system component What?
only the tab key ;t, C �
Y ,
cursor-do not
use the return A. Facility Information
key.
Q Address or Lot#
CHyfrown r
2.®*TYPE F SEPTIC SYSTEM*:
pump cavity(choose lane)
***If pump system,attach copy of electrical permit to application***
onventional 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
/j"/'� Y.?.- P a m.' /r j t.
Name
'r6) 0L_" /_/V .
Address(if different from above
P 11\1"S'.
l,'
City/Town state Zip Code
Telephone Number
3. Installer Information
Name Name of Co RISES,INC„
111 AR ILLA ROAD
C. `..I I 1X0 R.1 A
Address .,.
City/rown State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information/-
Name Name of Company f
Address
Cltyfrown State . Zip Code
i a :.
Telephone Number(Best#to Roach) .
Application for Disposal System Construction(Permit rage t of 2
SEPTIC SYSTE.Ivi.INSTALLER PROJECT MANAGEMENT OBLIGATIONS
for the construction f¢r�the septic systern for the property at:
As the North Andover licensed installer
For plans by /U
I'
(Address of septic system) (Engineer)
Relative to the.application of And dated
(in'staller's name) ---P—rig—tnarHateF
Dated With revisions dated
(Today's ate (Last revised date)
I understand the following obligations fur management of this project:
1. As the installer, I am.obligated to obtain.all permits and Board of Health approved plans prior to
perfoxtning any work on a site. I must have the approved clans 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, atui required to.have.the necessary work completed prioY;to the.applicable inspections as
itidieated below: I>tirtiierstand that re uesttn an iris ection without com letion:of the items in accordance
with Title 5 and the Board of 14ealth Reulafioins nay result in a$50 00`fine beine.levied aeainst:me..and' or
inv eowanv.
a Bo m of Bed=Generally,this is the first.(1°tj inspection unless.there is a tetaining wall,which
should•be done,,Arst. The:install sriia Tel.
Cluest the inspection but does
riot have to be present.
b. Final Construetori.Inspeetion Engineer must'firs :do their inspection for elevations;ties,'etc.
As-built of verbal OK(or e-mail to,healthde..pt townofnorthandover.com)from the engineer must
be stibriiitted-to..the Board of Health,after ovhich instailer.cails fqr 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 arid,alarm to functton.. :.
c. Final:Gta d&—Installer must request inspection when ll grading is complete...Installex does not
have to be-on-site.
4. As-the installer,'I understand that only 1-pay perform fhe w.oik'fotber than simile 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 b .others udlicensed.to install se tics stems in North Andover can con'st tufe
reasons for denial of the system andlor.revocation or suspension of my license<to operate in.the Town.of
North Andover, si&nificant fines to all Nelsons Jhv6lved are alto possible.
5.. As the:installer, I understand that:I xnuisk* on-site during the.perfoxmance of the following construction
steps:
a. Determination that.theproperelevation of the exca'vatlon has been reached.
A Inspection ofthe°sand and stone to be used
c. Final inspection by Board ofFlealth staffor consultant.
d. Installatron..oftank,D-Box;pipes,stone, vent,primp chamber,retar,'riing walland other
components.
6. As the installer,I understand that I am solely responsible for the installation of ihe.system as per the
appro ved plans No instructions by the homeowner general contractor -or any other persons shall-absolve
me of this obligation.
a (Today's Date)
Undersigned Liceised Septic.Iinstallez:
(Name,— _.rant r
m F p'
I�Ialie ti fr tip i � y _
TODAY'S DATE
r� ructi n it °�°
d
ORTH $ 250.00-Full Repair
01 $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of uildinCl: ❑Residential 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 V this Board of Health.
F -
� r-
Name Date
Ya' tian Approve �y: (Board of Health Representative)
Na �� r Dateation ®isappro "'for the following reasons:
For Office UJ Qnly:
1. Fee Attached? Yes No
2. Project Manager Obligation Form Attached? Yes No
3. Pump Svstem? If so,Attach copy of Electrical 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