HomeMy WebLinkAboutHealth Permit # 6/19/2014 i
a l /
Commonwealth of Massachusetts Map-Block-Lot
106.60144
BOARD OF HEALTH Permit No
North Andover BHP-2014-0628
P.1. FEE
F.I. $225.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-B-ateson
- - - --------------------------------------------------------------------------------------
to(Construct)an Individual Sewage Disposal System.
at No -7--OLYMPIC-LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2014-062 Dated June--18-,-2014
Issued On: Jun-19-2014 BOARD OF HEALTH
T � of tion for i N _ ..wryK P/
'S
Construction Permit - TOWN TC7DAY DATE
NORTH ANDOVER, MA 01845 250.00—Full Repair
$125.00-Component
Important: Application is hereby made for a permit to: RECEINED
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use epair or replace an existing on-site sewage disposal system*
only only the tab key
to move your El Repair or replace an existing system component—What?
cursor-do not L OW1 U O 'N,� 9 t i lH Akk D( Vf..af�
use the return A. Facility Information HEAL F i�l� r FIAF�, ViC i�a
key. f,"
Address or Lot#
City/Town —
, „ 2.®*TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump El"Gravity(choose one)
***If pump s item, 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)
Y ❑ Pressure Dosed (D-Box Present)S.A.S.
> ED-Does the system require an effluent filter? Yes d„ "„,. . No
If yes, does plan specify make and model of filter? Y ,Y (no further info. needed)
NO o(installer must specify brand of filter before®WC issuance)
ghat is the Make. Wliat is die Model.
2. Owner Information
Name — —
t
Address(if different from above) �)
City/Town State Zip Code
Telephone Number
3. Installer Information
. '44 _
----- - --- --
Name Name of Cornp r f.W,,)N PKI`L nPHSES INC,
- —1 — — ANDOVER,tl to tC_l
CAI-)
Address AN
------
R,MA 01,91U
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name rr,, Name of Company
”
W. s,
---- ------ --
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for Septic Disposal System
TODAY S DATE
Construction Permit - TOWN OF
$250.00-Full Repair
NOR'T'H ANDOVER, MA 01845 $125.00-Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: " esidential 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. I understand that until a final Certificate of Compliance has been issued by
this Board of 1,ealth, the installed system is not approved.
Name _ Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use Only: /
Z Fee Attached. Yes 11 No
Z. Project Manager Obligation Form Attached. Yes No
3. Pump S sy tem? If so,Attach coPy ofElectrical Permit Yes No
4. Reviewed approvalletter, all paperwork received. Yes No
MlsSl,
5. Foundation As-Built. (new construction only): Yes No
(Same scale as approved plan)
6 Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEP'xIC SYSTEM•INSTALL--EI�'PEGjj3CT MANAPEMENT'OBLIGATIONS
As tl}e•North Andover-licensed nstallex for thb conttrgtOpn for.,the septic systetp far.the,prope�rty at:
Fox plans by
(Address of septic syst (Engineer)
Relative to the•application or Ahd dated -
(in'staller's name) rigma .a,e .
Dated 3 I With revisions dated
o s a e (Last revised date)
I understand the following obligations for management of•this project: ,.
1. As the installer,I am.obligated to obtain.all permits and Board offHealth approved plans prior to
;performing any work on a site: I must have the an'roved,Bans and the�ermit:on site when any work is
bling
2. As the installer,.I,must••call-for any and a H:inspe'Ctions: 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.b .applicable. „
1' Astha rtstajle4 I anaAquired to,have.thi oecessu woik'conmpleted•ptiot'to the.applicable inspections as
_,,,. p p etiofl of the'itenls in accordariee
indicated belc�wYe i�+idetrs'tand that rea:;�'s��n.,g a� �,r• �t com �'
T. e 1 e s
a,. Bo't�oYri f .edti generally,this'is the firs: .(1"j:�'spe mon lxnless•.there is a retaining�yA which
should-be dt�ie 1Yrst Z'he uistall r niu t egpost tit iiispecOoll but sloes-not have to be present.' .
b, Tina tt'"n• ns eetiori—E mvs't first do their inspection for elevations;ti'e¢,etc.
As-bi3ilt of vetl7al OK(or e-mail•ro:lrealtlidpp-to o orthand'o`ver.�oin).from the enginaer must
be stibmi'tted•toli2e.Bcgtd'ofRealth,a6ex:whi6l .Mstadr•calls for•an insp•ectipn time. 'In-staller must
be present for this,inspection, With�a*putnp-system, all•elecCrical work;must:be ready and'able to
cause;pump.to-work and:alarm'•to function.. .
c. .Find]Gtade installer must request.inspection vvheh'o l grading•is complete:..Installer-does not
have to be on=site. '
4. As-the installer,'I un'ders`•tand that only I.I=y pedb=the.work•(other thart:(imple excavation)and1 ani required
io complete the-installation of the system identified in tfic•attached.`application for ih-stallation:: uttlie ..
Undera nd'•that z. =k done by.Otli'ers uiiyi'cen d to'mstalf.se tic,systems•ia North Andover can'conji4t it'e-
reasons for denial of tht•sy=andjor; evocation o'r su§'t5en'si ofty lieense.to operate in.the Tovvn.of
2jorth AndQyer_si�ficant fines.lo all porso'ns iti'volnetj` re also 12os`sible,
5..
As the.instxller,elnnderstand that.I xn itl' e•on-,site during fhopir&iidancepf the following construction,'
steps:.
a: Detetp2ingdOli that,theprop efevadba of the-ekeamdon has-been reached
b. raspeetron of the sand and std pe-to be used,
c. 'Prnal fnspecdorr by Board oi)�exlth staffor consultant.
d. .lnstahadon.•ofwnk,D-Box,pipes,stone, vent,pump chamber, ret-liOL g wall and other .
components.
6. As thg installler. 1=A rstand that 1gin sblfjy respo�lr for the installation of the syftem as per the
gpp sd p and No instructions by fhe hem pUer,gentmf.conira=r,,or,amy o tier.•persons shall-absolve
me!pf l is obligation.
Undersigned Uceased Scptic.Iinst;tUex:
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