HomeMy WebLinkAboutHealth Permit # 7/11/2016 yt�CLEDI � Commonwealth of Massachusetts Map-Block-Lot
® 107.A0173
BOARD OF HEALTH Permit No
North Andover BHP-2016-0226----
FEE
$175.00
ISPOSAL WORKS CONSTRUCTION I'T'
Permission is hereby granted Todd Bateson
to(Repair)an Individual Sewage Disposal System.
at No 337 SUMMER STREET---------_------__
as shown on the application for Disposal Works Construction Permit No. BHP-2 1-6-022 -Dated July 11,2016
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Issued On: Jul-11-2016 BOARD OF HEALTH
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/
TODA"Y'S DATE
Construction penwit
M!! ull Repair
NORTH AND 845 ornpon t
Important: Application is hereby made for a permit to: a,
When filling out ®Construct a new on-site sewage disposal system*
forms on the
onlythe�tab key ®Repair
epair or replace an existing sy fem eompo e t disposal
Whats
to move your
cursor-do not
use the return A. Facility information
..
key. 33 f'
Addressor Lot# NO }-
Cityll own '�' ,.
2.-*TYPE OF SEP'T'IC SYSTEM*: � � ��c��I��I� �r���°�
9 ❑ Pump Gravity(choose one) O
***If pump system, attach copy of electrical permit to application I jrjklJ V1 I E RTM L
A ❑Conventional System (pipe and stone system)
➢ []Infiltrator or Blodiffuser(Gravel-less)(Attach a copy of your certification to install this type of system.)
A ❑ Pressure Distribution S.A.S.(No D-Box)
➢ ❑Pressure Dosed(D-Sox Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES=(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Maker' What is the M0&41
2. Owner Information
Name
Address(if different from above)
4;r r o��-_
Cityrrown State Zip Cade
Telephones Number -
3. Installer Information
N C.a
ame Name of Company 91I ARILLAVIOAI:,')f
A i- ANDOVER, MA 0-1610
Address
Cityrrown State c'' ! Zip Code
Telephone Number(Cell Phone#if passible please)
4. Designer-Inforgyabon
Name Name of Company
Address
Cityfrown State Zip Cade
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
d�TH Applicati-on..for Septic Disposal :SS stern /,
TODAY'S DATE
F AConstruction -Permit = TOWN -OF
*•��r�
•ORTH AND OVER MA 01,845 $.250.00-Full Repair
��s•.�. ,� $125.00,-Component
. PAGE 2OF2
A. Facility.Information continued....
S. Type-of Building: esidential Dwelling or(]Commercial
B. Agreement
The underslgned 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 Issued this Board of Health.
Name Date
A o ro d By: (Board of Health Representative)
< < I (0
e Date
Application Disapproved.for the following reasons:
For Office Use Only:
1 ''Fee Attached?: yes No
2,• Projectltlatraget Ohligatioa Form Attached. Yes No
31; P-MJ2&E tem? Ifsoi Attach cQQv ofElectrical Petmrt`; 'es No
4. Fouada#on As Budt.?(new constructlon•ronly): -Yes No
(Same scale as apptoYed plan)
5. F1oorPlans?(new constructlon*only): Yes_ No
App.6tlonlor,0lsposal yster t:Constractlon Permtt'-Page 2 02
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