HomeMy WebLinkAboutHealth Permit # 5/15/2013 Commonwealth of Massachusetts Map-Block-Lot
038.00173-----------------------
BOARD OF HEALTH Permit No
BHP-2013-0718
North Andover
FEE
$125.00
DISPOSAL, WORKS CONSTRUCTION PI~RMIT
Permission is hereby granted John-Souc---_-_-___---_
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to(Construct) an Individual Sewage Disposal System.
at No 236 SUMMER-STREET--------- -----------------------------------------------------------------------------------------
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as shown on the application for Disposal Works Construction Permit No. BHP-2013-071 Dated LC!_ - - -___-
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Printed On:May-15-2013 BOARD OF HEALTH
3
1
=aetaQ or"e+yQO� Application for Septic Disposal System
JA
Construction Permit - TOWN OF Y
$250.00—Pull Repair
ORTH ANDOVER. MA 01845 $126.00-Component-
SSgCHUSE - -- j/
Important: Al2plication I§hereby made fora ermit to: vvV
When filling out Construct a new on-site sewage disposal system*
forms on the
computer,use ❑ pair or replace an existing on-site sewage disposal system* r
only the tab key
to move your Repair or replace an existing system component—What? ig
cursor-do not
the return
key- A. Facility Information ,
ray Address or Lot# �y L/
rerun itylI own
2.-*TYPE OF SEPTIC SYSTEM*:
❑ Pump VGravity(choose one)
*'`T pump system, attach copy of electrical permit to application"*
,Conventional System(pipe and stone system)
❑ Infiltrator or Blodlffuser(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.S.
2. Owner Information
me
Address If dill rent from�bove)LmLeK
n.itylrown State - q Zip Co/dCeJX
1 o,_3 s- �j�' �33q
Telephone Number
3. Installer Information
tau �- s� �,� S AY,® vUiCe
Name Name of Com any
-1i n
Cityrrown state Zip ode
Telephone Number(Cell phone#ifpossible please)
a. Designer Inform ion
Name V Name of Company
Address
CitylFown state Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
%tVRTlq A lication for Septic Dis osal System 1� ,
OF iaa r+q'Y
�a. 4- ��a4 Construction Permit — TOWN OF 7°°A rs
M w
ORTH AND OVER, MA 01845 $250.x0-Full Repair
$125.00-Component
9SSxcNUS�t
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: oesidential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site se a disposal system in accordance with the provisions of Title 5 of the
Environ e l Code,as well as the Local Subsurface Disposal Regulations for the Town of
North nd ver,and not top a the system in operation until a Certific a of Compliance has
bee ass d by this Boar of ealth.
L
me Date
Appli I on Approv By: (Boar JfHealth Representative
Date
placation b appr ed for the following reasons:
For Office Use only:
1.^ Fee Attached? Ye Na
2. Project Manager Obligation Farm Attached? Yes No
3. .=pSvstemP Ifso,Attach cowv ofElectricarl Per ri Yes No
4. Foundation As Bu&P(hew construction ronly): o
(Same scale as approved plan)
S. Floor Plans?(brew construction only): s No
Application for Disposal System Construction Permit•Page 2 of 2