HomeMy WebLinkAboutHealth Permit # 11/2/2009 Commonwealth of Massachusetts Map-Block-Lot
107.A0018
a Board of Health Permit No
North Andover BHP-2009-0693
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'"• :°LL , ` ' P.I. FEE
4CWu k�{� F.I. $125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
to(Repair-D-BOX ONLY)an Individual Sewage Disposal System.
at No 136 RALEIGH TAVERN LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2009-069 Dated November 02 2009
Issued On:Nov-02-2009 Boatel of Health
Application 1� . , " Y -
� �% a TODAY'S DATE r i it
* 'r
4q .ag %we 4. 250.00—Full Repair
m '4 ,
c✓�W �.1 $125.00-Component
CHUS
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Important: out A talica®Construe a new e on-site sew
When age disposal system
fillip
forms on the
computer,use ❑ Repair or replace an existing on-site sew olsisposal cyst w�/� i'
only the tab key - , ,', . I,1
to move your repair or replace an existing system co:poi
cursor-do not
use the return
key. A. Facilit y Information
rQ Address or Lot#
City/Town
2.-*TYPE OF SfiPTIC SYSTEM*:
❑ Pump 19°, ravity (choose one)
***If pump system, attach copy of electrical permit to application***
M-donventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
El Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
Name -
�. ( .., .w-. �
Address(if different from above)
City/Town State Zip Code
Tele 3 one umbe
3. Installer Information
Name Name
Address
n
�-o.w ,C� ®� _�.Y � ✓""' ✓`wd B ti„a.:iv w:i�y � „ m �, a a a dw�
City/Town —� State Zip Code
feleph no Number(Cell Phone#if possible'please)
4. Desioner Information
Name Name of Company
Address
City/Town State Zip Cade
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page t of 2
�0w7H Al Apgfi qation for S Posal Sy§fqm
TODAY'S DATE
Construction Permit - TOWN OF
a $ 250.00 ®Full Repair
4° 4
Q
' $125.00 -Component
SSACNU'�k
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A. Facility Information continued....
5. Type of Building: kg 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
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
d
✓ " �/ ° ..
been issued y this Board of Health.
el
Name„ ” Date
Application Approved By: (Board of Health Representative)
Name, „ Date
Application Disapproved for the following reasons:
For Office Use Only-
1. Fee Attached Yes"„I j No
2. Project Manager Obligation Form Attached. Yes f' / No
3. Pump S®ystem? If so,Attach copy ofElectricalPerrnit Yes I No
4, Foundation As-Built?(new construction roniy): Yes �0. No
(game scale as approved plan)
9. Floor Plans? new construction only):( y) 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 system for the property at:
A,
(Address of septic system) For plans by
(En - ee
Relative to the application of— r. / s�* ✓
(Installer's name) And dated
Dated � C ngtn ate
14, �t �
To3ay's ate With revisions dated
(Last revised ate)
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 the approved 121ans and the permit on site when any work is
being 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. 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 (15)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 OK(or e-mail to: healthdept @townofnorthandover.com) 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 (other than.ample 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, 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 ofHealth 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.
Undersigned Licensed Septic Installer: (Today's Date)
c c
(Name—Print) a — igne