HomeMy WebLinkAboutHealth Permit # 6/13/2016 o,
o ,Y���•r.�,�,6 Commonwealth of Massachusetts Map-Block-Lot
® 090.B0047
BOARD OF HEALTH Pen„ItNo
North Andover BHP-2016-0203
-----------------------
P.I.
FEE
F.1. $175.00
DISPOSAL WORKS CONSTRUCTION I'T'
Permission is hereby granted John DiVincenzo
to(Repair)an Individual Sewage Disposal System.
at No 400 SHARPNER-S POND ROAD
as shown on the application for Disposal Works Construction Permit No. BHP-2016-020 Dated June 13,2016
Issued O Jun-13-2016 --------------- -------- --------------
-- BOARD OF HEALTH
Y
S
1& $350.00 pll� ti on for B Septic i t y
Construction Permit — T F TODAY'S DATE
ANDOVER,NORTH 0145 - Full Repair
$175.00-Component
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 ❑ R air or replace an existing on-site sewage disposal system* 7
only the tab key - t
to move your [B Repair or replace an existing system component®What? '
cursor-do not �
° -
�
use the return Facility n
y O r ke . matl0
Address
rya ----
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
Y ❑ Pump4," ° ravity(choose one)
***If pump sy m, attach copy of electrical permit to application*** 'j'OW�O NOM�i AND CUM
i`U'�
➢ a onventional System (pipe and stone system) HEM-1 H U IR 4'rME tl
Y ❑ 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)
❑ Pressure Dosed(D-Box Present)S.A.S.
Y ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES =(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make? tt%hatis the Model.
2. Owner Information
Na ---------------
Address(if different fro abov -�
City/Town State Zip
Email address _f�elelAone NZImber
3. Installer Inform tion
o
Name Name of Company
Address
City/Town State Zip 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
ti on for Septic Di I y t
TODAY'S DATE
Construction Permit — TOWN F
NORTH $350.00-Full Repair
01845 $175.00 -Component
PAGE 2 OF 2
A. Facilitv Informati n continued....
5. Type of wilding: Residential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal ystem in accordance with the provisions of Title 5 of the
Envir n ental e, a ell as the Local Subsurface Disposal Regulations for the Town of
No do er. I nd stand that until a final Certificate of compliance has been issued by
thi B rd f I h, a installed system is not approved.
--- e "a Date —
roved Representative)
a . , pp ,�( bard of ealth Re resentatrve � �„
ppli�ati n A y'
r z
Date
Application Disapproved for the following reasons:
For Office Use C1nly:
1. Fee Attached? Yes_L,1 No
2. Project Manager Obligation Form Attached? Yes rte/ No
3, Pump Sys tem? If so,Attach copy of Electrical Pe rt Yes No
Applicant received copy of
"Electricallnspection Notes far Septic Systems" s No
Handout?
4. Reviewed approvalletter, all papet•wotk received? Yes No
Missing'
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
G. 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 At dower licensed installer for the spnstt uction f r the septic system for the property at:
(Addre s of septic System)() For plans by
Relative to the application of - (F nl sit
('Installer's name) And dated
(Original date)
Dated "
oe ay s c at:e With revisions dated
(Last rc.6ssy41 ciat<:°)
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 prior 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, 1 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 dze 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 fast do their inspection for elevations, ties, etc.
As-built of verbal OIL (or e-mail to: licaltlyde t ij)towii(::)f'tiorth,tnc]()ve,r.coaii) 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 systern, 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 sill1ple excaivilioli)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 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 tank, 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 home ner neral contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer:
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