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HomeMy WebLinkAboutHealth Permit # 4/21/2009 Map-Block-Lot "ORTH Commonwealth of Massachusetts 105.0-0079- ----------------------- 3FO�`t Board of Health PermitNo o BHP-2009-0511 North Andover FEE E, ' P.I. $250.00 SSACw �i5�4 ----------------------- F.I. Disposal Works Construction Permit Permission is hereby granted John-Soucy----- ------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. atNo 980 FOREST STREET ----------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2009-051 Dated __April 17,2009 Issued On:Apr-21-2009 Board of Health �s 9i tin for tiC i S t ---- t _— -- TO 'S CAA E Construction Permit n $ 250.00—Full Repair -. n . .. ORTH ANDOVER, MA 01845 $125.00 -Component Important: Application is hereby made for a permit to: When filling out E] Construct a new on-site sewage disposal system* forms on the 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 A. Facility Information key. rab Address or Lot# erum City/Town —t �� ✓"� 2.® *TYPE OF SEPTIC Y °T W: Pump El Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) Infiltrator or Riodiffuser(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-Sox Present) S.A.S. 2. Owner Information V.r — --- Name — � �- Address(if different from above) City/Town - -- — State Zip Code Telephone Number 3. Installer Information �0'x Name Name of Company Addre�� 4 City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Informatio n F- –a of Company� -- �-` `�,✓1. �'�,�(��� Name N me� � � Address _Pe a gar o'_-�_ - City/Town 1 — State Zip Code Telephone Number(Best#to Reach) Application for disposal System Construction Permit•Page 1 of 2 Application for Septic Dis osal SYstem Construction err it — T TOD DA E MA ORTH 01 $ 250.00-�Full Repair L $125.00 - Component PAGE 2 OF 2 A. Faci lit Inform ti n ontinue .. 5. Type of Building: esidential 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 Environ . tal Code, as well as the Local Subsurface Disposal Regulations for the Town of North A� over, and not to place the system in operation unt"1 a Ce ificate of Compliance has been&s ed by this Boar f Health. .- - �,�I - - -P --- ------ Name Date Applicatigh°Approved B Board of Health Representative) Name Date .n Application Disapproved for t e following real ns: For Office Use Only: Z Fee Attached? Yes No Z. ProiectManager Obligation Farm Attached. Yes No 3. Pump System? If so,Attach copy of Electrical Permit Yesl� No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 3. 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 Andover licensed installer for the construction for the septic systein for the property at: l For plans by � ti (.tclG.ls�kss of septt( system) F,rigi neQ:)` Relative to the ap lication of �4 ��` — (Installer"s natne) And dated r�ri��tn< �ate,,i Dated t l With revisions dated � b oa av,c ate (Last revised data';) 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 Rrior to performing any work on a site. I must have the approved plans and the permit on site when any work is being doge. 2. As the installer, I 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 the 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 first do their inspection for elevations, ties, etc. As-built of verbal OIL (or e-mail to: hwealtl t„ t,?to yL7?crf i` rt-ra,i la r c,a ia) 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 system, 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 (atber Than simple exeawlion) 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.1 am solely responsible for the installation of the system as per the approved plans. No instructions by the ho eowner, general contractor or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: ;ttaie:.......Print) aide igne Date... ..ZJ..... .. .. ' NOR7M TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SSACHUS� This certifies that ...Z.- ........ ✓. ?. ....................................................... has permission to perform - � �-/'� wiring in the building of............... L �' `�........... ... ............................................ at.. ..../ '......... .......`:.. .... .................... ,North Andover,Mass. Fee.s .............. Lic.No.. ......... ............................................................... 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