HomeMy WebLinkAboutHealth Permit # 8/10/2004 rlrr-+f.1y���frtrf;✓r.n1��y3'�s 9��f�/tf/��� iltd ��,r✓2t�7�..r✓l f,+./ll r� ,'""�, "'� ""�„",,,' ," -_-------
r fF�l r�ft�%`ft3351✓aa9'f'��Yf,�rn�ix�tf,'� �t tf,�'�' r
f /r cr- k t J /f ,r,f 0171CYlOflWea���1 O �aSSat"N ettS- Map-Block-Lot
10
f1 " , I ' ,. l , r ,/ i of✓ {,' 5.B-0003-
O g(.,
ea'th
� a � O � Permit No
BHP-2004-0571
I ( r', .:fire t ��f� r.. .,(r = fif?'rr ';:IYO,ftI1":,At1dOVe
Z
OR
✓; FEE
� $250.00
-
r�� ��� a � Consrucion Pernnit
P(t��� ��x�/�ra��t�a�'✓.; � � ��x sr� i r�� r f f ""
1TLOT
�ar �qS��i� ��fi�f?�x� -<” urt ''"' fl" "�rf' t��� r ---; ?'_• -
����
(�r'� ",rr��JPd"�6JYrn��� ,Ri"�, f� '� �i�'�r„'r`/,,rf��J rrsfP„°,/9,rr`7�.a✓s� 't fi.,
�tirrl`r� r�� rfr'G��r "�����t x��'--'s�'r✓',�` �.�f,',W���,' ����`s� --- -- -__ .
�� �,�� � tit „'" ��st�` /n��� �,1 a,tGl�ir'�r r�r�xff✓yf
g 20.04
rt tt r x 'ns
Works Construction PerinitNo BHP 2004 057 Dated August 10
-_
t✓'r lIr��� r.f4i �t�l�/f� rt7,=✓�r��-:�b`ftf ���1`_v't'h�f9.tr/-3r t "" '" ;-"'":" ";`; .," '
rr' �J?;�'I ��,1r',�:. 3 l,rrjex�ta"'f en✓ /33n r n,� �(Y'r.m� ,^.: F�>' r rl�" 1
If�.,, �!��Lnxn .✓ nf`l r'l „9Y,'ra;� s'/' ,l tr r ,ls�'
�P s''%�'It9 �� 'Y,'�'f�r� ✓?s�r fl��w'tn�nlf �''�i f�x � ,' .;�� r a,
/p sey fns lr�Jtrt
O�rCl Of Health i
�J;a^�l tlf��!/r������✓,�� .r��l�j>d�/�a'�.✓�hn�"`'1��r f�f+u�r� >'� :. ',; „." ;,,,, ", ,"" :';'s "` ;,,r ', _ ___
rr��r ...............................................
i"rltar73 r✓✓ ;Jrrrr art . 'Ye3j,/ll/r-rat✓f!✓r/'✓f�' .✓ e" .!!t?r'rr u.... .. .uur�.u■ ....ri.....
�r�ntif�fti+"ati r�rK xL�■ a�}i+ rr i'w�K.1�itiwrY',,�wiGt h�Y+4''i� .ti�t �7n r■ ,: ,, ,,,;:," ,;,., ?ew,�„..,�
�L,1,r 'l rf.✓u�fi�i, e r n.r to �l„ vin %.,t,
Y
't
TOWN OF NORTH ANDOVER
Office of COMMUNI'T'Y DEVELOPMENT AND SERVICES
0 n
HEALTH DEPARTMENT ),
27 CHARLES STREET
NORTH ANDOVER,MASSACHUSETTS 01845 ASS 4CNUSE�
Susan Y.Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.9542—FAX
heal thdept C)townofnorthandover.com
www.townofno7•tliandover.com
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE, `?.. w, IV'
.....
.... ..........
LOCATION:
LICENSED INSTALLER NAME: ' trr / � ,
PLEASE PRINT
SIGNATURE: ,. b c _ ' .... TELEPHONE#
CHECK ONE:
FULL SYSTEM REPAIR:
COMPONENT REPAIR (indicate what parts):
* NEW CONSTRUCTION: I
If NEW CONSTRUCTION,please attach the Foundation As-Built Plan.
$250.00 Fee Attached? Yes °° No
Project Manager Obligation From Attached? Yes ,
No
Foundation. As-Built? Yes No
Floor Plans? Yes „✓'%° 'i No
i
Approval of Health Agent .d ,� �., .„.... Date:
c
(
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer Dor
property at 4""/"'%'1 relative to the application
of dated for pans by and
dated wUNromacmud
'
I understand the following obligations for rnanagerne4 o[(Ibim 'uut:
L /\o the installer Ioon obligated iw obtain all permits and Board o[Health approved pkma prior
to performing any work on u site. I must huve the approved plans and the permit on site
when any work ix being done.
2. As the ivaiu\)e, Iuoua( call for any and all inspections. If homeowner, contractor, proJect
manger, or any other person not associated with my company schedules an inspection and the
system iu not ready then item three shall bcapplicable.
3. As the inaruUor I uon required 10 have the ooceaaurY work completed prior 10 the applicable
inspections as indicated below. l understand that rcgooudng uu inspection, without
completion of the items in accordance with Tile 5 and the l9nurd of Health Ke8nlxdonx may �
|
result in u$5O.O0 fine being levied against my coonpaoy.
o) DoUnm of Bed genet-ally 6cat inspection unless /borc is u retaining vvul| vvbioh should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — BoAinoor mma\ Dn/ do {hob inspection for elevations, 6oa. o/o. Au-hoU, or
voz6a| 0K from engineer must be ouboiUcJ to Board of Health, o8or which installer coUu for
inspection time. Tnn|oOur mumt be present for this iuupociioo. With pump system all o|unt600J
work must bc ready and able 10 cause pump to work and x]aooiofunction.
c) Final GruJo—lnmaUormuo/roguco<ioopcoduu when all grading is complete. Does not have to be
on site.
4. As the installer I understand that only I may perform the work (other than simple excavation)
required to c*oqp|oie the installation of the system identified in the xUoob*d application for
ina(uUoiioo. l further understand that work by others unlicensed to install septic uya\ooux in
North Andover uun unuudiu\e reasons for denial of the uyaiern, and/or revocation or
aoapomoiwo of my license to operate in the .[ovvu of North Andover; significant fines to all �
|
persons involved are also possible. �
5. As the Ioa|u]lec I understand that I o/nxt 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 tobuused. |
c) Final inspection by Board of Health xtoD,orconsultant.
d) Installation of \auk. D'hox, pipos, o,ouu, vnu\` pump okambor, retaining vvaU and other
onmpoonom.
6. As the installer I understand that I unu ou|cly responsible for the inw(uJ|udon of the aya|cru as
pet- the approved plans. No instructions by the homeowner, general uwoiruuioc, or any other
persons shall absolve rncof this obligation.
Undersigned Licensed Septic Installer
Date:
Disposal Works Construction Permit#