HomeMy WebLinkAboutHealth Permit # 11/15/2004 Town Of North Andover,+0
0 Massachusetts
TO
BOARD OF HEAL
Form No. 3
Ix,
us
DISPOSAL WORKS CONSTR
Applicant (JC-rION PERM,,
Site Loc4tion__ ADDR
Ao
TELEPHONE
Permission is hereby gr
Sewage Disposal anted to U�nstruct ns
pair a
system ( I Or Re Individual
as shown the Design A n pproval S.S. No.
Soil Absorption
Fee C1 CH, RMAN, BOARO FIEALT,
D.W C• No,
TOWN OF NORTH ANDOVER i 's
Office of COMMUNITY DEVELOPMENT AND SERVICE,
HEALTH DEPARTMENT 00- 0
L_
27 C11AR1,ES STREET ^,
NOWITI ANDOVER, MASSACHUSETI'S 01845 o S olus
Susan Y.Sawyer,REIIS/RS 978.688.9540-Phone
Public Health Director 978.688.9542--FAX
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www.towiioftioi-thandovei-.coiii
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:_J I/1 /0
14ov i mv�
LOCATION:
LICENSED INSTALLER NAME: JIyCVW
PLEASE PRINT
SIGNATURE: TELEPHONE#
...........
CHECK
ON
FULL SYSTEM REPAIR: ($250)
COMPONENT REPAIR (indicate what parts): ($125)
NEW CONSTRUCTION: I/
If NEW CONSTRUCTION, please attach the Foundation As-Built Plan.
..........
$250.00 or $125 Fee Attached? Yes
Project Manager Obligation From Attached? Yes No
Z'
Foundation As-Built? Yes No—,,--
Floor Plans? Yes No-..,-.—
Approval of Health Agent Date:
�
,
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INSTALLER PROJECT MANAGEMENT OBLIGATIONS
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As the North Andover licensed installer for the construction of the septic system for the
prop%ty at 0 41 relative to the application
and
of ',�-dated for lans by
dated with revisions dated—
I understand{he'fo|}mvviuA obligations for muuuguuientofthis project:
).
� � theinstalierIarn obligated to obtain all permits and Board of Health approved plans prior
10 performing any work on uxh�. Imust have the upp.v,", plansandihe permit onsite
when any work ia being done. .
2. As the inakzDurl must call for any and all inspections. If homeowner, contractor, prm]oo�
manger, or any other person not associated with my company schedules an inspection and the
system iy not ready then item three shall beapplicable.
3. As the ioo|u}bcr I am required in have the necessary work completed Prior to the mPp|ioub|u
inspections as indicated below. T understand that requesting an inspection, without
o onp|utimu of the items in accordance with Ii)o 5 and the Ioun] of Health Bogu\u1iooa may
result iun$5O.O0 fine being levied against ouycompany.
x) Bottom of Bed - gonozxDy 6ro{ inspection unless \boo is u retaining wall which nbun\d be done
first. Installer must request the inspection but does not have tubnpresent.
b) Final inspection - Engineer must first Jn their inspection for elevations, &oo` etc. /\u'buUi or
verbal OK from uoginvc, must be submitted to Board of Boubh, after vvbioh iumtuUnr calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must bc ready and uh|u to cause pump to work and alarm to 0/oohon.
c) Final Grade-Installer must request inspection when all grading is complete. Does not have to be
on site.
4. As the installer Iunderstand that only I may perform the work (other than simple excavation)
n:guinzd to complete the installation of the system identified in the u8ucbcd mpD|iouiinu for
installation. I further understand that work by others unlicensed Voinstall septic systems in
North Andover can onuehtuto rcu0000 for denial of the oyuk:no, and/or revocation or
suspension of my Ucuoae to operate in the Iovvo of North Andover; xiguiO000t fines to all
persons involved are also possible.
| 5. As the Installer I oodunLuod that I must be on site during the performance of the following
�
construction steps:
| u) Determination that the proper elevation of the excavation has been reached.
6) Inspection of the sand and stone{wbuused.
o) Final inspection hy Board of Health staff o/consultant.
d) lum(a|}odou of (onk. D-box, pipes, stone, vent, pomp chamber, retaining *m|| and other
|
components.
6. As the ioukdkr Iondem1mud that l um solely responsible for the installation of the system as
per the approved plans. No iuuUoo(ioon by the homeowner, general contractor, or any other
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persons nho|| absolve rnoo[this obligation.
Undersigned Lice nsed Septic Installer
Date: /*
Disposal Works Construction Permit#
/
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fror4-1
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION
4�j 4 ****�*te
+ r
APPLICANT G PHONE
LOCATION: Assessor's Map Number k PARCEL L_L4
SUBDIVISION LOT(S)
STREE �
.. ST. NUMBER.
USE ONLY************A*****
RECO ` ENDAT O S, F TOWN AGENTS:
d
CONSERVATION AD INIS ATOR DATE APPROVED
DATE REJECTED
COMMENTS i
PLANN R DATE APPROVED �} J
DATE REJECTED
COMMENTS
{
FOOD INSPECTOR-- LTH DATE APPROVED
DATE REJECTED
S INSPECT HEALT DATE APPROVED
DATE-REJECTED
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS_
DRIVE7,Y PERMIT
FIRE DEPARTMENT /
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9W jm
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