HomeMy WebLinkAboutHealth Permit # 4/15/2003 Town of North Andover, Massachusetts Form
jORTH BOARD OF HEALTH
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DISPOSAL WORKS CONSTRUCTION PERMITp"�'��n
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Applicant
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Site Location
Permission is hereby granted to Construct ( ) or Repair (-n Individual Soil Absorr
Sewage Disposal System as shown on the Design Approval S.S.
GH RMAN, BOARD OF HEALTH
9
Fee D.W.C. No._. /
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTAL 14R:
SIGNATURE: TELEPHONE#—&
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$175.00 Fee Attached? Yes No
FOLinclation As-built? Yes No
Floor plans on fije Yes......... No
Approval
---------- Date:
TOWN'OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( )constructed;
( )repaired;
by D �.
located at t t
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit.# ,plan dated , with a design flow
Of gallons per day. The materials used were in conformance with those specified
on the approved plan; the system was installed in accordance with the provisions of 310
CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with
the approved plan. All work is accurately represented on the As-built which has been
submitted to the Board of Health.
Bed inspection date:
Engineer Representative
Final inspection date:
Engineer Representative
Installer: Lic.#: Date: �- -o
Engineer: Date:
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North-Andover licensed installer for the construction of the septic system for the
property at N-i.Y TS_relative to the application
of dated for plans by and
dated with revisions dated
I understand the following obligations for management of this project:
I, As the installer I am obligated to 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 is not ready then item two shall be applicable.
2. 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 Tile 5 and the Board of Health Regulations may
result in a$50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection tune. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be
on site.
3. As the installer I understand that persons or companies not associated with my company may
riot perform the worse required by my company to complete the installation of the system
identified in the attached application for installation. I further understand that work by others
unlicensed to install septic systems in North Andover can constitute reasons for denial of the-
system, and/or revocation or suspension of my .license in the Town of North Andover plus
significant fines to all persons involved.
4. 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.
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff.
d) Installation of tank; D-box, pipes, stone, vent, pump chamber, retaining wall and other
components.
5. As the installer I understand that I am solely responsible for the installation of the system as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve me of this obligation.
Undcrsi Licensed Septic Installer
e2v Date: 1,J-
Dispos 1 Works Construction Permit#