HomeMy WebLinkAboutHealth Permit # 10/20/2011 • � Commonwealth of Massachusetts Map-Block-Lot
� 038.00170
BOARD OF HEALTH Permit No
North Andover BHP-2011-0811
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P.I. FEE
F.I. $250.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd_Bateson
to(Repair-FULL SYSTEM)an Individual Sewage Disposal System.
at No 196 SUMMER STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2011-081 Dated October 20,2011_
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Issued On: Oct-20-2011 BOARD OF HEALTH
„aRrw lip i S em
ab,•14T I®roaa {� pig p� f06DAY a DATE
250.00®Full Repair
pro a $725.00®Component C us
Important: Application is hereby made for a permit to:
When filling out ® Construct a new on-site sewage disposal system*
forms on the
computer,us® UKepair or replace an existing on-site sewage disposal syste
only the tab key "o°°E I V
to move your El Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information C kC't I
key.
rd Address or Lot#
, uu Citylrown
2.-*TYPE OF SEPTIC SYSTEM*:
®.Pump Gravity(choose one)
one)one)
***If pump system,attach copy of electrical permit to application***
® Conventional System(pipe and stone system)
nfiltrator or Blodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
®Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement)
®Pressure Dosed(D-Box Present)S.A.Q.
2. Owner Information
Name , 4 V
e” y
`T
Address r different from above)
City/Town state g Zip Code
Telephone Number d
3. Installer Information
k)AeO
SAT N EKITE FniQr:* ilki%
Name Name of CompanY111 ARGILLA ROAD
Jfl 41"'y P. � A�DC�V t,M,01aid �
Address
..
Cityfrown Sta#e Zip Cade
Telephone Number(Cell Phone#if possible please)
4. Designer Information
w .✓r
I( N 1 tl^'"e. ^.'"' �A4�.. YY �'C C +` Qi.,��b,.. ^P"•d:;i p" °1'w.+$':04 5
Name Name of Company
$ c
Address
City/Town state � Zip Code`l
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit.Page t of 2
potwrN q Ann!Lcationfor tic Dis osa stem
TODAY'S DATE
p
Construction Permit — TOWN OF
* $.250.00-Full Repair
♦ $125.00 -Component
�SSAC14USk4
PAGE 2 OF
A. Fa6ilitv.Information continued....
S. Type of l391iding: 0<esldential 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
been issued by this Board of Health.
Na Date
Application A raved By: (Bo d of Health Representative)
Name Date
Ap ation Disappr ed for the following reasons:
For Office Use
L FeeAttached9 Yes No
2. Project Manager ObEgation Forte Attached Yes_,° Na
3,; Pump.ystem? If sot Attach copy ofElectdcalPertnit Yes No
4. FoundatibnAs-Budt.?(new construction ronly): .Yes 4` No
(Same scale as approved plan)
.5: Floor Plans?(new construction only): ;Yes_ No
r
Application for Disposal systermconstruction Pen-nit.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:
(Address of septic system) For plans by `'-
(Engineer)
Relative to the application of
(Installer's name) And dated j e
ngina date).
Dated
(Iocia '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:plans and the permit on site when any work is
being done.
2. As the installer,.I.miust 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.
3.4 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 Boatel of Health Regulations may:res iltin�a$50:00 fine beingaevied against mean lot
in,. c�ompan�;
a. Bottom of Bed=Generally,this is the first(1'�inspection unless.:there is a`retaining wall,which
should be dorie, rst. The'installet 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:healtl del2t@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 mustbe ready and able to
cause,pump to work arid.alarm to function..
c. Final Grade—Installer must request inspection when 4ll grading is complete. Installer'does not
have to be on-site.
4. As the installer,'I understand that only I may perform die 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 bv.others ur3licensed to-iiistall selitic systems in North And 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 musfbe on-site during the.perforrnance of the following construction,
steps:
a. Determination that,the proper elevation of the excavation has been reached
A Inspection of the sand and stone to be used.
e. 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 tilans. No instructions by the homeowner, general contractor,or any other persons shaft absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date) to /3 f f
ame- Print
fir` z1: d fit/ e