HomeMy WebLinkAboutApplication - 55 LOST POND LANE 7/26/2012 aORTW rl I f r1 1 I
stem
ToDAYS DATE
250.00 Full Repair
$125.00 Component
sACKU'
Important: A21 lication is hereby made for a psi rvtit too
When fiirng out ®Ganstruct a new an-site sewage disposal system*
farms to the p 0 ° g disposal Y a
computer,use an existing stem component What?
only the tab key Repair or replace an existing an-arts sewage eats ass s stem
to move your epair or replace 9 Y
cursor-do not
use the return A. acility Information
key. r
Address or Lot#
CWTown
�r)Vur er r�i apx.X i ff fiwu�r@¢a bVfl�i�
2.-*TYPE OF SEPTIC SYSTEM*:
�]pump cavity(choose erne)
***If pump system,attach copy of electrical permit to application***
onventional System(pipe and stgne system)
®Infiltrator or Biodiffuser(`ravel-Less) (Attach a copy of your certification to install this type of system.
Pressure Distribution S.A.S.(No D-Sox)(Attach Draft Maintenance Agreement)
®Pressure Dosed(D-Box Present)S.A.§.
2. Owner Information
. it A u
ti. '..�9aa✓.
Address(if different from above)
691 Y,
Cityfrown State G Zip Code
Telephone Number
3. Installer Information
Name Name of Cam arty t19 AN l R®ACS,INC.
d .
Address I
Cityfrown State Zip Code
Telephone Number(Cell Phone#lfpossible please)
4. Gesioner Information
Name Name of Company '
Address
City/To n State Zip Cdde
Telephone Number(Bast#fo Reach)
Application for Disposal System Construction(Permit.Page 9 of 2
�d�r� , �Ir fl r fi . ' I y f , .
G qt"®is Np
may, ,`, a ap r ®. TODAY'S DATE
o f' n r if
$,250.00"Full Repair
AeHUS $125.00.-Component
PAGE F
A. ecility-Information continued....
5. Type of 13uildinet: sidential Dwelling or EDCornmercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title S of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
a' North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued b Board of Health.
_Name Date
Application A, roved By: oard of Health Represent; ye)
Name Date
Applleatior Disa0proved for the following reasons:
For ®fiice Use Only:
1 Fee Attached. es�/ No
2, ProlectManager ObEgation Farm Attached? Yis No
9, PuW 5 stem? Ifsoi Attach copy of Electrical Pertnrt`. ''eo No
.7
4. Foundadon As Built,?(new construction ronly); Yes_ No
(Same scale as approved plan)
.5 Floor Plans?(new construction only): Yes No
Appilcation•for Mposal System Oonstruction Permit Rage 2 of 2
SEPTIC SYSTEM.-IN$T- LL ER PROJECT 1ViANAGEMENT OBLIGATIONS
As the North Andover-licensed installer for the construction for.,the septic systern.for.the property at:
For plans by
(Address of septic system) (E eer)
Relative to the application of k �1
1�� And dated
(In'staller's name) a e .
Dated With revisions dated
o a s ate (L st revised date)
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 prior to
performing any work on a site. I must have e approved•plans and the perinit on site when any work is
the
Uin
�-ng_done•
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.L As tlie'iastaller,I*atzi-required to.have.the oecessary.work completed priaY to the.applicable inspections as
indicated below: I iiitiietstand that rec uekin�an inspection,without completion:of the items in accordance
with Title 5 and the Bbatd of lgeaitli Regulations may result in a$50 00 firie'bein .levied'aeainst me-and/or
inv dom any. ,
Bo6ti!Hof Bed-Generally, this-is the.first 1 tns ection'unless.there is a"retaitiin wall,which
"� P g
shoulcl'be doiie< rst: 'Tlie`installer hiiist:request the inspection but does.not have to be present.
b. Final-Consttuctio .Itnspeetioti—Engineer Tn st first:do their inspection for elevations;ties, etc.
As-built ofw.erbal OK (or e-mail to:healtlidept0i wnofnorthandover.com):from the engineer must
be submitted to the Board of.Health,after:whcli:installer.calls for.-an inspection time. Installer must
be present for
this inspection, With a pump system;all electric al-work.,must'be ready and able to
cause,pump.to work and-alarm ao fiuiction..
c. Fina_tGtade Installer must request inspection when ll grading is complete...Installer does not
have to be-on=site.
4. As-the installer,•I understand that only I itay perform the.work (other than:simple excavation)and I am required
to complete the-installation of the system identified in.the attached application for installation: .I fiiith
.understand.-that work donee others ui3licensed to install septic systems•in North Andover can constitute
reasons for denial of the-system and/or revocation or suspension of-my lieense,to operate in the Town.of
North Andover, significant fines to all persons involved are also )ossible.
5. As the:installer,1 understand that I must be on.site during the.perfortna'nce of the•following construction.
steps:
a. Determination,that.the proper elevation of the eveara.tion has been reached
A Inspection ofthe sand and stone to be used
c. Final inspection-by Board ofHealth staff or consultant.
d. Installation.,of tank,D-Box;pipes, stone, vent,primp charirer,retaining wall ansl other
components.
6. As the installer,I•understand that lam solely responsible for the installation of the.system as per the
apprplans No instru ctions by thehomeowner,general.contractor_-or any.other persons shall-absolve
me o€'ties obliagtion.
Undersigned Licensed Septic.Installer: (Today's Date) a c /