HomeMy WebLinkAboutHealth Permit # 5/13/2016 s '
Commonwealth of Massachusetts Map-Block-Lot
® 10630109
BOARD OF HEALTH -----------------------
Permit No
North Andover BHP-2016-0154
FEE
$350.00
DISPOSAL WORKS CONSTRUCTION I
Permission is hereby granted Todd Bateson
to(Upgrade)an Individual Sewage Disposal System.
at No 32 OLYMPIC LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2016-015 Dated May 13,2016
------ ------- ------- -------- ------- --------------
Issued On:May-13-2016 BOARD OF HEALTH
r
7�
yt�r
J2�
r
�i
�f
��s
fJ3Y
l
tion for Septic Disposal Svstem 13
Construction Permit — TODAY'S DATE
NORTH ANDOVER., MA 01845 $250.00—Full Repair
$125.00-Component
Important: Application is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal system*
rms on the
computer,use M11epair 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 A. Facility Information
key. C,
Address or Lot#
Cityfrown -/�'" - MAY { ,:y �')0
2.-'TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump ravity(choose one) 'UA,84 OF M 1RM-4, f4[)OVER
***If pump system, attach copy of electrical permit to application— H M.1 G p DEi'%RflME111'11 i.
> ❑Conventional System (pipe and stone system)
➢ Wnfi itrator or Biodiff user(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.
➢ ❑ 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®WC issuance)
W111at is die Make? What is theModefsffl'
2. Owner Information -
Name
Address(if different from above) pl
Cityfrown State Zip Code
Telephone Number
3. Installer Information
Name Name of Compa
yrf 6 f r'r's 1r'fl�;p' INC.
Address J
Cityfrown State Zip Cod
Telephone Number(Cell Phone#lfpossible please)
4. Designer Information
Name w Name of Company
Address
Cityfrown Wo 6.,x r. State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit.Page 1 of 2
Md^THE A_ pplicati•on..for Septic Disposal :System 1 _
n•• ti
3?•��, ��•oe� -�,� TODAY'S DATE
F -onstruction -Permit = TOWN- OF
�* ' ORTH AND OVER MA 01'845 $.250.00"Full Repair
�'S "•� '
GNUS $`125.00,-Component
s^ '
PAGE 2OF2
A. Facility.Information continued....
5. Type'of Building: esidential Dwelling or❑Commercial
B. Agreement
The underslgned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system In accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system In operation until a Certificate of Compliance has
been Issued by-thIs Board of Health.
-f0
Name f Date
Application App vetl Ry:(Board of Health Representative)
Name , ��T'
•�• Date
Ap�llcation Disapproved for the following reasons:
For Off*ce Use Only
I •Fee Attached,
Yes No
2,• PtofectMariaget Obligation Form Attached? Yes
No
31: P ystem.? Ifso)A tra ch CQRV OMA trical Permit'•; Xes— fro
4. Foundation As Built,?(hew construction•ronl}r, Yes_ NO
(Same scale as approyedplan)
5, F1oorPlans?(hew construction only): Yes
No
Applfc tlon(or•p(spp5al System: onatructlon Penh;Page 2 of 2
SEP `tC'S5 MA q . -OBLiGATIQNS
As f$e.NgrthAndover•lia=etlaiatxIla f sr4 te•tdtfstxgcdQtI f6x•'t61eptia system-for.the Propetty$t:
{Ada iA9 ofs**sjtae} FarpUto by l<<' �6✓
ReU&e to spp}fttdpu of iz S
(itai et'�acme Abd dated d
Dead °
� 1
(40aaa : Vfth Mvidaat dated
(L=t revised date)
I undmtaad the following obligations fat nwmgt atcmt offbb P.tolcct♦
i. lA the iattallesy I am.abligateti tp obtxia allpt aad'Boatd of -Ieaith ppravcd plants to
�pez iag attp:wolk da3 St Ohm I m_uat have th 9 a And flie n •�,�, . .
. .M @ie sa�tslle>y.I•;utiatscaII for miy anti itA aaPtx iiuta: I£hamt awtte contractct4 psojectman Str,or any
o herpataoiz not trat}ot 3�cd with my taampaap h4et-an iasp&#om sad the spatefin is not trady,thcit
itcmdttee•a�tl.}t�,n�pl�tble. •
•'� M.tik I r req ed to bare c steam y war7c 1 thc.app tb�e i apectipo its
diiseA •
tt��MTT
- tt.. 5 '"`.� •�tt�•ia�k�k.�l��'p��- s:thotc is a; gam,�clr
shtka'I t be dan ;# lob xsiat �li�## fat 6t P=004 taut ea-not have to be present',
• . • '6` - •., • . �'•—_ oetmi�t �la•t �ap��far eiev,iliona�des,ct+c. •
Aa t a 'viecbxl OIL"(ar el etfgirtart mast ba taubiriicted td 8vtad•ofHcaW s "benth far iii=xmn�:e
£pn ti .'7eststlJax ifiiit
'PU&P q$tM3 *A e►lectdctlwtirk at be reu}y and able to
ptitt4p.tti'to�ork i6 ' • ,
t" # ;: — idu€tnlltr tartar s�aque�tuapectroa t�►hgitll gttiitta t'.tspltte: Iststalicr does szot
We to ba bn#&e.
4. As-the iam Ilet,•I u�u that tmly l p p the tQaflc"�at6ert6atr=t a fain and 1
Feu aarpiete Eliotttt of the spatgt iS fq#1i itedippYiaii £os mixed
art: itietaltatlon: .
4
tea n far denial;of tht andl' " cY�nt�er a�± nn R•IF"I— t$-
MaA Andim ficant�qes Mid
5.. Zia the#aat tlea;.I tttit#efttnitd 6-fT man tt c ti ith pace-of the folicavii$coastx4c
Det�ern�ast�o�tliat.d'�ep�perrle�dcia aftlre�c5svat�atr hs�•,��s+e�abe,al- - '
' . b. Itrspt��fiaa af�rlic""®imrd�ad��exb7�e tamed ' '
A AQMWAMtPCC *oVbpjjo uota Tee ttb ar orcoVfuhant
d [ tYa dit �I$AtWI rat pau�p chtmber,r ft4ft W9ff a other .
eampa0MOV
b.
Win �ii ,vsr-a if"131o88L�fC
• + r—'! ,
Uudt and b=mM SgWc.jft%ter: : (i<'ptM ixte
•• .