HomeMy WebLinkAboutHealth Permit # 8/8/2016 — Map-Block-Lot
Commonwealth of Massachusetts 106.c0020
BOARD OF HEALTH >?eritx°
BHP-2016-0250
North Andover
FEE
P.I. $175.00
-
F.l.
DISPOSAL WORKS CONSTRUCTION PERMIT
Todd Bateson -------------------
- ----------------------------
Permission is hereby granted -------- ---------
to(Repair)an individual Sewage Disposal System.
at No 73 CARLTON LANE - -------
as shown on the application for Disposal Works Construction Permit No. B 16 025 bated _-#ugust --- 2016---------------
BOARD OF HEALTH
Issued On:Aug-08-2016
---� —
Application for Septic Disposal System
TODAY'S DATE
construction Permit - TOWN OF Pull Repair
C,
NOR'T'H ANROVER, MA 01845 $1 ' Component
Important: Application is hereby made fora pgrmit 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 EWepair or replace an existing system component—What?
to move your
cursor-do not
use the return A. Facility Information
key.
Address or Lot#
V L116 3
W A G (J
_C_ityf�own_____We��,,
-.2 *TYPE OF -row�4 FNOPTH A10ME11
-" SEPTIC SYSTEM
)7
❑—PUMP -B'G-ravity(choose one) j,m tL[J-1 DUMJ
*.*If pump system, attach copy of electrical permit to application-
> ❑Conventional System (pipe and stone system)
> ❑Infiltrator or Blodiffuser(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.
➢ F] Does the system require an effluent filter? Yes— Na
If yes, does plan specify make and model of filter? YES=(no further info. needed)
NO=(installer must specify brand of filter before DIMC issuance)
Wh at is the Make? what is the Modefez
2. Owner Information
i&ne
- --ab--ove)
(if different from
-Address
A/ Zip Code
State
6it_yrro�w_ n
Telephone Number
3. Installer Information
-Name Name of oMMON r_urERPnISl=8*, INC.
111 ARGILLA►`10AD
4^
_FV
Address
-ditty—!Town State Zip
'_,C!/.
of+`
ode
et erg
Telephone Number(Cell Phone#if possible please
4. Designer Information
Name Name of Company
Address
_6110IT-own Zip Code
Telephone Number(Best#to Reach)
Application for Disposal system Construction Permit•Page 1 of 2
.. A iipafion far Septic DiS�posa! .. S ern
H
pS Constiruction -Pprmrit -•- O C rooArs DA
O `C)RTH :1 NDOVE ,� NI 41;845 $.250.06 T pull Repair
�ss emus $125.00.-Component
PAGE 2 OF 2
A. Fac lity. nformation continued....
6. Type,of Building: esldentiai 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 Regulatlons for the Town of
North Andover, and not to place the system 1n operation until a Certificate of Compliance has
been Issued .. this Board of Health.
t�f Name pate
A P, d ti n, proved (Bo ore fh Representative)
a e
' Gate
Application Disapproved.. "orthe following reasons:
For Office Use Only: "
1 ,-Fec Attached? Yes No
2. Prajectll?axiaget C1blrgatioa Farm Attached? Yes + ; ` No� :.
3.; BM A& `rn? If voi Attach copy ofElec&C111 Pexmil ; No
4. Founaratr'azr As Burk:?(hew constructlon,ronly); -Yes No
(Same scale as apptoyed p&a)
5. FloarPl=s?(new Construction'only). No
Appifd struckion F�ermtt Rgaes 2 ;r n
5FP' `fC'S S S'Y'l 1Vt IN �IL,T R4, �G ` 1f llt+J�: ONT. PIJGA TIPM
As fl�*Nptth Audovargo=sad bsuffia fps tlt a#r t fpx �pitc t i `a .the�I r etty u�
(Ad4vUofI**ipft4 /' P'cmpIms by ...
R�hfine to dw4ppucaton of °y '1�e Cdr✓
AM dAW
.:d �
Ducd �
(IAW. eufseddate) �
I undmftd the following Obligations fat manu meat Of0a pIVIect:
i. 1i�tha.iastslicr,I itm•tabligtstod�obtt�.aiFptx�q>ita su��aard�f?�atith�PP��F���� -
4)e&mft at►p:wo*cia a aita• .
2. As :I i II 07� Kati stRA� a: Ifho�acpron�4tc*ntrnc r&maw or axe
o*mpcnon trot oc6ted eta my ic=psay tt IW=ivape#ofl�the sptedn�' is nct=cjythgft
item 9mcahatim t+tppli�atble,
As .c �q ed AppUMble ittapiedogy as
ie ited.
�,: neraity� p - t fir,
ttht d b dtnS p ��t a acdotx i t t ea•nothgve tcrb4 pnirde,
f, —_ 3ti�i¢t�t C p i7d1{tyf ckft*Its;*'etc
flat o 'i► i?3i1 OT�'�os a t x ftnm the ed&pa mr<st
ba#ttbmittMCd•tci Sc*rd'of•Hadk&I ' • im� €orii i 6p=tipn time,7jstaait�
he t at t fajr th ,iupc b xey t ad able to'
cam pomp•to+odoattc to - ..
' ;� � ��—�at�illet:m�t�qugt'is�eccirya�rhe��11•g�cri#s���s+r.�npl�te: I�st�srdor��at
4. As-the iast IM-I tad thilt oi�p 4my P �c xac�c'{slhn• r�,im, W►dau) IAvi• *amd
t t
jGa .digit of the ttytti ti #1►� �ro :f inst�d[atian: -
'S,. A�ti�e.�t�lle,�Y u��tnit� t'.I� `�•t�'t tdu���h�•ptx•of tfi�foIiog oam�st�c�iat:►
Ai N�A-
s +r: Dc aadoant t15wt.t p 'P&cfcv &a aftlie cva"daua*4 beep rc- Chca7t
1 IpxtfaRar aftbe'ia�d uad etbe usrd
C 'PfadAWpca faro by vaga tS"'&01r &"cm.eulfda dt
d -aft t afttk,LP%ffOA� SAW* mkgtsPr mmp Wamirath" .
f
vnd���S�tic.i�ts�r• „� - .. . trpt�����, ��� ��