HomeMy WebLinkAboutHealth Permit # 8/13/2010 Commonwealth of Massachusetts Map-Block-Lot
105.D0021
Board of Health Permit No
~ BHP-2010-0704
® North Andover
-----------------------
P.I. FEE
$250.00
F.I.
DISPOSAL WORKS CONSTRUCTION IT
Permission is hereby granted William T. Sawyer
to(Construct-NEW SYSTEM)an Individual Sewage Disposal System.
at No 657 FOREST STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2010-070 Dated August l3,2010
-a
Issued On:Aug-13-2010 Board of Health
f
0 lication for Senfic Y t o _... �....R _
on truti Permit TODAY'S DATE
�
1 ANDOVER.� � 018 $250.00—Full Repair
a
� $125.00-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 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
key. A. Facility Information
rya Address or Lot#
Cit /Town
Y
2.e*TYPE OF SEPTIC SYSTEM*:
❑ Pump 7,,Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
❑Conventional System(pipe and stone systern)
-Infiltrator or Biodiffuser(Gravel-Lees)(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-Box Present)S.A.S.
2. Owner Information
Name
Address(if"different from above)
-- ------------------ ---------
Citylfown State Zip Code
Telephone Number
3. Installer Information-
IA.) ����� uu � et
Nam ) t Name of Company
Address
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. . �
esi Har In orm ion
Nam e ` a a Name of Company
Address
Cityfrown State Zip Code
Telephone Number(Best#to)Wach)
Application for Disposal System Construction Permit-Page 1 of 2
m .M pplication for Se tip Disposa 6 :;z
a � TODAY'S DATE
can tru tin Permit - TOWN OF
� w ORTHANDOVE MA 01845 $250.00—Full Repair
$125.00 m Component
PAGE 2F2
A. F ility Information continued....
5. TY� ®f �uildlrig: Residential 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
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
North Andover,and n t to place the system in operation until a Certificate of Compliance has
been issued by this B and of Health.
`.. .... ..mm... ... _.. ..__ _ ..,.. __._..._..._...._ _ ....�...
Name Date
Appiicati rr'Ap ved By: (Board of Health Representative)
NamZation Date C..
/111 Disa roved for the following reasons:
For Off ice U t�nly:
1. Fee Attached? Yes " No
2. Project Manager Obligation Foem Attaclied? Yes No
3. Painp System? If so,Attach cotry of Electrical Permit Yew � No
4. Foundation As-Built?(new construction ronly): Yes k,.° No
(same scale as approved plan)
5 Floor Plans?(now construction only): Yes_.,,'- No
Application for Disposal System Construction Permit•Page 2 of 2
SEP'T'IC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
--�(Address of ,a adP .y �xnl For plans by d�
"�
Relative to the application of s v �o�i p u^ 66�✓ (_1 yy
And dated
)ngmH date)
Dated
J
— ---4 t o auPr s(W7,T — with revisions dated d ...._q',a k. / .
(Last rcviscd date)
I un 11-4—nhlia-ations for management of this project:
�rmits and Board of Health approved plans pdor to
a„ (
he approved plans and the permit on site when any work is
pections. If homeowner,contractor,project manager,or any
....., y schedules an inspection and the system is not ready,then
cessary work completed prior to the applicable inspections as
r, �" " °° g atn inspection, without completion of the items in accordance
ions may result in a$50.00 fine being levied against me and/or
he first (1'� inspection unless there is a retaining wall,which
Lust request the inspection but does not have to be present.
'ngineer must first do their inspection for elevations, ties,etc.
eta tiP li:w�cirP �)t a yjI L);it'jort i..tndoyar.x tt'i,) from the engineer must
t,after which installer calls for an inspection time. Installer must
uc Pl._a, __ 1 a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Gracie–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(olber lban single excavation)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, sigtnificant 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 ruched,
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 homeowner, general contractor,or any other persons shall absolve
me of this obligation.
' s Date)ate)
Undersigned Licensed Septic Installer: iij (Tod,
"r
SYSTEMS INC
This is to certify that:
William Sawyer
Arco Excavators
has satisfactorily completed the required training program for the installation of the
INFILTRATOR"leaching chamber system for on-site wastewater disposal applications.This
person is certified to install the INFILTRATOR" chamber system as set forth by the
Massachusetts DEP approval letter for INFILTRATOR drainfield chambers, All other
guidelines as set forth by the latest revision of 310 CRM 15.00 of Title 5 will apply.This
certificate was sealed and issued 12131/2007.
Certification:h1A2187
Lee Verbridge
Atlantic Regional Manager