HomeMy WebLinkAboutHealth Permit # 8/14/2012 i
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• Y�r,. Commonwealth of Massachusetts Map-Block-Lot
0
• 109.00044
BOARD OF HEALTH ---- -----------------
Permit No
North Andover BHP-2012-0708
P.1. ------------ -- --
FEE
F.1.
$250.00
DISPOSAL T [J TI I'T'
Permission is hereby granted Robert K. Daigle,Jr.
to(Repair)an Individual Sewage Disposal System.
at No 555 BOSTON STREET
as shown on the application for Disposal Works Construction Permit No. BHP 2012-070 Dated August 1,4,2012
----
-------------- _r------ ---!--- -----------------
Issued On Aug-14-2012 BOARD OF HEALTH
t
r
a lip ti n for Se toy i 9 y stem / lc ,
.uv
Construction Permit ® TODAYfS D TE
O ` H O E A 01 45 250.00-Fu Repair
.,...:�Oa -Component
Important: Application is hereby made for a permit to:
When fin
forms on the filling out F-1 Construct a new on-site sewage disposal system*
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. A. Facility Information
CAddress or Lot# ,'"°
XI._
av n City/Town --
N
Z.- *TYPE O' SEPTIC SYSTEM*:
❑ Pump Gravity (choose one) �
***If pump system, attach copy of electrical permit to application*** f
❑ Conventional System (pipe and stone system)
nfiltrator 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 Zip Code
Telephone Number
3. Installer Information
'd 9 a
t 1 %
-----------------
Na a Name of Company
dress -
City/Town State Zip Code
Fi
�e
Telephone Number(Cell Pho ne#if possible lease)
4. Designer Information
Nam Na a of Company
IAd ss
w
y
Cit / - - -
n State Zi Code
Telephone Number(Rest#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
kw lip ion for tip i I y t _ J a-
Construction Permit ® OF TOM t D TE
ORT H ANDOVER. MA 01845 $250.00-Fun Repair
CM $125.00 -Component
PAGE 2 OF 2
A. Facility Information ontinue ....
5. Type of Building: UIResidential 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 the Local Subsurface Disposal Regulations for the Town of
North Andover, and n t to pi a the system in operation until a Certificate of Compliance has
been issued b this oa d o Health.
T. _ 0_ _
N e Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use Only-
1. Fee Attached? Yes No
2. Project Manager Obligation Farm Attached? Yes Na p..
3. Purnp System? If so,Attach copy afElectrical Pelmrt Yes { No
4. No
4 Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only). Yes Na
Application for Disposal System Construction Permit•Page 2 of 2
YctEn, Commonwealth of Massachusetts Map-Block-Lot
109.00044
------ ---------------
BOARD OF HEALTH Permit No
North Andover BHP-2012-0676
P.I. FEE
F.I. $125.00
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted Robert K.-Daigle,-Jr--------------------------------------------------------------------------------
to(Repair-D-BOX&OUTLET PIPE)an Individual Sewage Disposal System.
at No 555 BOSTON STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2012-067 Dated June-27-,-20-12
------------------------------------------------- --
Issued On: Jun-27-2012 BOARD OF HEALTH
p
.................
F,
` f
SIC I n for agptic DiF ,'� 8 System
TOD4'SDATE
Construction Permit - TOWN OF
ORTH $ 250.00—Full Repair
^� ANDOVER,MA 01845 $125.00 - Component
CHU6
Important: Application is hereby made for a permit to: � '
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer, use Repair or replace an existing n g disposal y temp only the tab key
to move your Repair or replace an existing sy stem component What? �"t 06 ov,
�
cursor-do not
use the return A. Facility Information
key.
r� Address or
A iJN
ie�wn City own . P
fd� —
2.- *TYPE 4F SEPTIC SYSTEIW :
Vmp Gravity (choose one) `If pump system, attach copy of electrical permit to application***
nventional 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 Craft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
------ f ro - ----- ------- –
Name
----- ----- --- - -------
Address(if different from above)
City/Town State Zip Code
Telephone Number
- ---------
�
3. Installer Information
v',/
Name - Name of Company
Address
y .
o t
— � a. — 0 1 --
City�fown State � o Zi p,Code
Telephone Number(Cell Phone#if possible please)
4. Desioner 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
0 . .� ion for tip i t
.........
TODAY'S DATE
Construction Permit —.TOWN OF $ 250.00®Full Repair
" $125.00 -Component
1 cOU
PAGE 2 OF 2
A. acility 1n formation continued....
5. Type of Building: ❑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 t system in operation until a Certificate of Compliance has
been by this Boar Me h.
issu
Name Date
Application Opp ro,ved By: (Board of Health Representative) ' w
Name Date
/0'00
Application Disapproved for the following reasons:
For Office Use
1. Fee Attached. Yes_'" No
2. Project Manager Obligation Form Attached? Yes ° No
3. Pump Svstem? If so,Attach cop-v of Electrical Permit Yes No
4. Foundation As-Built? new construction ronly : Yes i No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit^Page 2 of 2