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Home My WebLink AboutHealth Permit # 6/17/2010 Map-Block-Lot wQd;xw Commonwealth of Massachusetts 107.A0231 ----------------------- ------ - ------------- b }� Permit No Board of Health BHP-2010-0619 North Andover g FEE P.I. $125.00 °�" gar•rs 1£' --------------------- _____ _ ______________ �s�ac�� fi F.I. DISPOSAL CONSTRUCTION I Todd t ------------- Permission is hereby granted ----------Ba--- eson ---------------- ------------------------------------------------------------------ to(Repair-OUTLET TEE)an Individual Sewage Disposal System. at No 45 SHANNON LAN -- ---- - - - - - --- - - --------- - ------ - - - --- --- ----- - - - - ----- - -- -- -- as shown on the application for Disposal Works Construction Permit No. BHP 2010-061 ' Dated._ June_17,_2 -------- -' - - ---- --- Board of Health Issued On: Jun-17-2010 v Application for SepLiq .._ 1j A .�"�'�`w'• "•�"r° °� TODAs DATE b Construction r m it Y" ' (��® 250.00�-Pun Repair �s,*�a';� � _ , ( $125.00 -Component SAC14U Important: Application is hereby made for a permit to: When filling out ® Construct a new on-site sewage disposal system* forms on the computer,use ® Repair or replace an existing on-site sewage disposal system* only the tab key to move your ❑ Repair or replace an existing system component—What?_ / cursor-do not use the return A. Facility Information key. re3 Address or Lot# City/Town a l„�„ .-*TYPE OF SEPTIC SYSTEM ump ❑ Gravity(choose one) ***If pump system,attach copy of electrical permit to application*** Conventional System(pipe and stone system) ❑ Infiltrator or Dlodiffuser(Caravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S.(No D-Box) (Attach Draft Maintenance Agreement) ❑Pressure Dosed (D-Sox Present)S.A.S. 2. -Owner Information Name Address(if different from above) Ak p,. ityfTown State Zip Code Telephone N s M umber 3. Installer Information Name NameofC mpany�ll ROAD' Address — City/Town State Zip Code Telephone Number(Cell Phone#Mpossible please) 4. Designer Inform ion ( _ Name Name of Company Address City/Town State Zip Cade Telephone Number(Beast#to Reach) Application for Disposal system Construction Permit•Page 9 of 2 Appl,ication for tip I TODAY'S DATE ..- A"). -Construction — TOWN OF Y 01$ 250.00- Full Repair ® $125.00 - Component �s$AcwUSk� PAGE 2 OF A. Facility Information Continued.... 5. Tv esidential Dwelling or ®Commercial . 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 been isspd„ by this Board of Health. N n Date /l Application Ap roved By: (Board of Health Representative) zx 'Tx z/ "'f :. :.m :> Name Date Application isappro ed fort, , following reasons: For Office Use Only: _ M L Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump Sys tem? If so;Attach co�nv of Electrical Permit Yes Na ._... ".w 4. Foundation scale as a tionAs-Brzilt. praved lan pn�w construction roil V) Yes No 9. 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 system for the property at: q % �� (address of septic system) For plans by _ (Engineer) Relative to the application of 0 (Installer's name) And dated ngma ate Dated 4� j(TocTay's-ate With revisions dated (Last 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 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: healthdeptntownofnorthandover.cow) 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 simple 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 gV12roved No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) �0 alme print) (Name,--,Signed)