HomeMy WebLinkAboutHealth Permit # 11/10/2015 e �t;�rt.eri��s•
® Commonwealth of Massachusetts Map-Block-Lot
® BOARD OF HEALTH 104.DO04z
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Permit No
North Andover BHP-2015-0905
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FEE
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
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to(Repair)an Individual Sewage Disposal System.
at No 193 FOSTER STREET
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as shown on the application for Disposal Works Construction Permit No. BHP-2015-090
_ ______ _ Dated November 10,2015
Issued On:Nov-10-2015
BOARD OF HEALTH
Y '
t -
r" a TODAY"S DATE
Construction 'Permit
2
' U—Full Repair
NORTH ANDOVER21-MA 01845 972_5.00
Component
Important: ADDlication is hereby made for a penmitto.
When filling out ® Construct a new on-site sewage disposal system"
forms on
omputer,h
c use El Repair or replace an existing on-site sewage disposal`system*
only the tab ey
to waveyour epair or replace an existing system component—What?
t k
cursor-do not
use the return A. Facility Information
key. i Y It'd ;rr
rm Address or Lot#
City/Town
2.--TYPE OF SEP , SYSTEM*;
A ❑ Pump ErGravity(choose one) '
" if pump syst m, attach copy of electrical permit to application"*
➢ onventional System (pipe and stone system)
➢ ❑ Infiltrator or Biodiffuser(Gravel-Less)(Aftach a copy of your certification to install this type of system.)
➢ ®Pressure Distribution S.A.S.(No D-Box)
D ❑ 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®(nor further infer. needed)
NO=(installer must specify brand of filter before DWC issuance)
whatis the Make? What is the Mod`cV
2. Owner Information .N
Name
Address(if different from above) /
City/Town State Zip Code
Telephone Number
3. Installer Information
� ,I"'i Name of Company any 1 l l A l L.L A h +)AD rear f�
Name ANDOVER, MA 0 l al 0
Address
City/Town -a State Zip Code
Telephone Number(Cell Phone#If possible please)
4. Designer In f qrnyaflon
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
TO®AYsoArE ••
RTH $.250.0®-Full Repair
A4W9� $725.00.-Component
�ncwus
. PAGE 2 OF
• ® Fadifty.Information continued.,..
5. Type,of gIldrin Residential Dwelling or[]Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-slte 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 lssu y this Board of Health.
/
Nem trite
A I , ti Approv
Q o ealth Representative)
' Boar
f/ Y
N me _ b2te
Application Disapproved:for the following reasons:
For Oft e Use n1V:
1 'Pee Attached?: Yes No®
2, Project&kdager ObYgatron Form.Attac&ed? Yes Na '
31: ' t'm? Ifso).Attach cotry ofElectrical Permrt';• Yew No
4 .F`bundadonAs-Built?(new Contraction ronly),, Yes No
(Same scale as a�rr,proved plan)
S. F1oorPlans?(new cortstructioni only): Yes® No
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