HomeMy WebLinkAboutHealth Permit # 4/20/2005 Town of North Andover, Massachusetts Form No.3
kORTH BOARD OF HEALTH
of .� ,,1tio ] �sl
11 O P
0
DISPOSAL WORKS CONSTRUCTION PERMIT
9SSACHUSE�
Applicant {
NAME ADDRESS TELEPHONE
Site Location /�� �►
Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No
HAIRMAN; ARD HEALTH
Fee D.W.C. No.
,rOWN OF'NORT11 ANDOVER
Office of"COMMUNITY DEVELOPMENT AND SERVICTS
HEAumDEPARTMENT
400 OSG001) 11USNORTI-1 ANDOV1 MASSACETTS 01845
978.68&9540 - Phone
Susan Y. Sawyer, REIIS/RS 978.6W9542 FAX
Pijbfic Health Director
,Lo
i a th e wq ifinorthandover.com-e-mail
wwrv.townofilot�ttiaii(lover.cotii -website
..........................................................................................
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
IRATE:—Xy//
LOCATION: 0 f
LICENSED INSTALLER NAME:
PLEASE PRINT
SIGNATURE: TELEPHONE# cp
............ ...............
CHECK ONE:
FULL SYSTEM REPAIR: ($250)
COMPONENT REPAIR (indicate what parts): ($125)
NEW CONSTRUCTION:
If NEW CONSTRUCTION, please attach the Foundation As-Built Plan.
..............
$250.00 or$125 Fee Attached? Yes r-" No
Project Manager Obligation From Attached? Yes No
Foundation As-Built? Yes No
Floor Plans? Yes k-`11_ No
Approval of Health Agent Date:
/
`
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the yen6cxymk�o�[ordh�
septic
�
od � d� ����o
property —relative application
of dated for plans by and �
dated with revisions dated 1/ /Z�)() L.(
I understand the following obligations for management o[this project: .
I. As the installer Iumobligated to obtain all permits and Board of Health approved plans prior
1npurfozo-fingany work on u »ito. Inmuat have the approved nluoo and the permit on site
when any work io being done.
2. As the installer onuo\ call for any and all inspections. If homeowner, contractor, project
manger, or any other person not associated with my company schedules an inspection and the
system im not ready then item three abaU be applicable.
1 As the installer Iaourequired |o have the ueo�aaacy work completed prior to the applicable
ioxyucdona as indicated ho}op/. I understand that rugucnkug an inspection, v/irboot
uonup)oboo of the itonny in accordance with Tile 5 and the Board of Health Regulations may
result inu$50.O0 fine being levied against uoycompany.
o) Bottom of Bed generally first inxpoobno uo\ooa there is o retaining wall which should be done
first. Installer must request the inspection but does not have tu6upresent.
b) Final inspection – Engineer must Gm| do their inspection for c>ovu6ona' ties, e\o. As-built or
verbal OK from engineer must be submitted to Board of Health, after which installer ooOu for
inspection time. Installer must he present for this inspection. With pump oyuo:m all electrical
work must ho ready and able to cause pompm work and alarm vofunction.
o) Final Grade–Installer must request inspection when all grading is complete. Does not have to be
on site.
4. As the installer lunderstand that only I may perform the work (other than simple excavation)
required to complete the installation of the mymienu identified in the oVucbod application for
installation. I further understand that work by others unlicensed to iuutuU septic uyotenoa in
2qohb Andover can oonod|o\e reasons for denial of the xyu{enu, and/or revocation or
suspension of my |ioouae to operate in the 7,ovvu of North Andover; significant Onna to all
persons involved are also possible. '
5. As the Installer I understand that I must be on site during the performance of the following
construction.steps:
a) Determination that the proper elevation of the excavation has been reached.
6) Inspection of the sand and stone k/6oused.
c) Final inspection by Bound of Health staff or consultant.
d) Installation of tank, D-box, pipes, amoc' vent, pump o6umhor, retaining nmO and other
oompnnxom.
b. As the installer I understand that l ucu solely responsible for the iookdludon of the system as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve nuemf this obligation.
Undersignp d L censed Septic Installer
(14L jl� (\J, . Date:
' r W
Disposal Works Construction Permit#
�
�
�
'
\R:?
�S.��$\
&`3§d|
( $ƒ«§� � ■ �/ �
ƒ � M
Oil
22§ ■ a
#r 2� ■f . ;
! , 2ƒ■, 2
al�a2
J I2�2 �