HomeMy WebLinkAboutHealth Permit # 7/27/2016 Commonwealth of Massachusetts Mat,-Black-Lot
106.00097
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BOARD OF HEALTH Permit No
North Andover BHP-2016-0235
FEE
$175.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
to(Repair)an Individual Sewage Disposal System.
at No 120 C.'AR.LTON LANE
as shown on the application for Disposal Works Construction Permit No. BI-IP-2016 02 ..,,..Date& July 27,2016
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Issued On: Jul-27-2016 BOARD OF HEALTH
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Septic Disposal Application for I -fd-DAY'S—DATE
Construction Permit - TOWN OF $250.00-Full Repair
NORTH ANDOVERM�A01845 $1,25.00-Component
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a now on-site sewage disposal system*
forms on the
computer,use E]Repair or replace an existing on-site sewage disposal system*
only the tab key -What?
to move your lepair or replace an existing system component
cursor-do not
use the return A. Facility Information
key.
Address or Lot#
IV
OV0,0
Im.
"4�" 2.-*TYPE OF SEPTIC SYSTEM*: lirNoi 11,E
❑ Pump ravity(choose one) —
***If pump sys�,-attach copy of electrical perm it to application
➢ B'Conventional System (pipe and stone system)
);- ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
➢ ❑Pressure Distribution S.A.S.(No D_Box)
➢ ❑Pressure Dosed(D-Box 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)
/ Wbatis die Make? w1lat is the mode4�___
2. Owner Information
Ido 61, 1
Address(if different AJA
CitylTown State Zip Code
Telephone"Number
3. Installer Information
Name of CoMPIATESON ENTERPRISES,INC.
Name
Address
0101 U
L ANDOVE
A-0 tA14
State Zip Code
City/Town �14_
Te—leph,hone Number(Cell Phone#if possible please)
4. Designer Information
_Name Name of Company
Address
_City Zip Code
aown State
_Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page I of 2
P
AppiiGation..for Septic i]ispasel : stern
TODAY DATE `
Monstruction -Permit-
C)�.T14 Nb0VE MA 01845 $.250.60,-FuliRepair
hip ssAC14US ,$125.OD•-Component
PAGE 2 OF 2
A. FacllityInformation continued...,
S. T e of Buildin : esldontial Dwelling or❑Oommercial
B. Agreement
The underslgned agrees to ensure the construction and mal'ntenance of the afore-descrlbed
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 Cerfificate of Compllahce has
been Issued b1s Board of Health.
• �„' .: . ,__.�� Date
Name
p is tion App By: (Board of Health Representative)
'
� x �
Name : Date ,
Appilc n Disa� rove¢ i. r t ie f 1 oin%in yeas ns. }
pu
For Offtae Use Only.
1 "Fee Attached? Yes Na
2,• PrajectAfldager O►blrgation Form Atta d? Yes Na '
3.: Pum, ;Stern? Ifso)Attach ca ►�of "lP ri.7l r`t:: 'es No
4. FouadationAs Burlt.?('new construction-ronly); es� Na
(Same scale as approyed plan) ---
S, F10orPlaas Mew construction,only): t'es No
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