HomeMy WebLinkAboutHealth Permit # 9/2/2008 Commonwealth of Llassa'%,.husetts Map-Block-Lot
107.A-0076-
Board of Health Permit No
North Andover BHP-2008-0178
• P.I.
"•,.�� .•'°a`= FEE
�s�acN�a�i F.I. $250.00
Disposal Works Construction Permit
Permission is hereby granted lames Kellett
to(Repair)an Individual Sewage Disposal System.
at No 456 SUMMER STREET
---------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2008-017 Dated September 02,2008
------------------ ---------------------------------------------
Issued On: Sep-02-2008
Board of Health �'
of N�Rt,9ti Application for Septic Disposal System �� '
-Construction Permit - TOWN OF
TODAY ATE
� ° ORTH ANDOVER, MA 01845 $ 250.00—Full Repair
•� 0.n..^ $125.00- Component
caug�t p
Important: Application is hereby made fora permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use J Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component-What?
cursor-do not
use the return
key. A. Facility Information
0rab1 Address or Lot#
V o'4C�
ityrrown
2.- TYPE OF SEPTIC SYSTEM*:
Pump E] Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ 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)(Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
Name
(� Al CA
Address(if different from above) c
IN rjA- Aykj,,, f b l p is
City/Town State Zip Code
Telephone Humber
3. Installer Information
st 1�
_�11 M VeAk° L _ lit tkay. EkC&V )r) -
Name r Name of Company
L[06 (AU
Tress h to
City wn State Zip Code
Tetephone Number(Cell Phone#if possible please)
4. Designer Information
<T cvAc 1M c C r✓ _ �Y�J\ Ass' Go c'�"s
Name ` J Name of Company
' nA
Address
Cityrrown State / /Zip/I Code�
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for Septic Disposal System
Construction Permit - TOWN OF TODAY'S DATE
$ 250.00 —Full Repair
ORTH ANDOVER, MA 01845 $126.00 - Component
CHU
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building:AResidential 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 Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
be issued, by thi,!BPard of Health.
/V
a e Date
Appli(�af Approved BW oard of Health Representative)
Dat
Application Disa"p'proved for the following reasons:
For Office Use Only:
L Fee Attached. Yes fI/ No
2. Ptoject Manager Obligation Form Attached? Yes No
3. Pump Sys ? If so,Attach CppE ofElectrical Permit Yeses' No
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SJ,-,PTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(Address of septic system) For plans by
(Flngnieer)
Relative to the application of( J li,;) A f&.-H
(hisaaller's name) And dated 7
-(Original date)
Dated 27'� oday's With revisions dated 9
I date)
0,asr revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any.work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. 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 Title 5 and the Board of Health Regulations mg result in a$50.00 fine being levied against me and or
MY company.
a. Bottom of Bed-Generally, this is the first (V inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection-Engineer must first do their inspection for elevations, des, etc.
As-built of verbal OK (or e-mail to: Lic-a-lit-ide
4it
) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a 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. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (olber d9an si&iple excavalim)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done 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 to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. 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 or consultant
d Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining waK and other
components.
G. 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.
7
Unders )day's 1)
rued Licensed Se Installer: ate
anic Print) �,)igned)
I
Commonwealth of r lassachusetts Map-Block-Lot
107.A-0076-
Board of Health
Permit No
North AndOVer BHP-2008-0178
-----------------------
4r '•.s�r •a.'�4 P.I. FEE
4S5AG1itJ �� F.I. $250.00 ''..
------------
Disposal Works Construction Permit
Permission is hereby granted James Kellett
to(Repair)an Individual Sewage Disposal System.
at No 456 SUMMER STREET
------------------------------------- ------
as shown on the application for Disposal Works Construction Permit No. BHP-2008-017 Dated September 02 200$
-------------------- ------------------
- ----------------------
Issued On: Sep-02-2008 j
Board of Health
p
tk p�:
n`y .o,+,tiA Application for Septic Disposal System ,
pConstruction Permit -- TOWN OF TODAY' ATE
ORTH ANDOVER MA 01845 $250.00—Full Repair
$125.00 -Component
s�C us
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer, use J Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
Y
q 5 4Q `��ter �� S+ .
ra8 Address or trot#
N14
2.- TYPE OF SEPTIC SYSTEM:
XPump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ 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) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
N `e
4S (.,
Address(if different from above)
Nj 0'rt _ J°4YC�ov� Q✓1 d � ����
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Company
kjob (AGM
A dress
nnr�4�
Citylown State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
� SSQLtc� rJ
Name Name of Company _--
Address
CitylTown State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
Application for Septic Disposal System
o
" Construction Permit - TOWN OF TODAY'S DATE
$ 260.00— Full Repair
ORTH ANDOVER, MA 01845
CHUS $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
s. Type of Building:,XResidential 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 Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
be issued by !th* B and of Health.
R!�q
e Date—
Applic 'i Approved B Y' Board of Health Representative)
V" /Af
Npr,Ke Dat6z/
Application Disapproved for the following reasons:
For Office Use Only:
L Fee Attached? Yes F No
2. Project Manager Obligation Fonn Attached? Yes No
3. Pump Sys ? If so,Attach cop v of Ele ctrical Permit Yes No
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit-Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(,Wdress of septic system) For plans by (Engineer)
Relative to the application of
(Installer's name) And dated (91
(0nT�_in_aTcT ate
7_
Dated rWp'� Id(,Ir"(),
f,I Way,S d ate) With revisions dated(Last revised(late)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work,is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item,three shall be applicable.
3. 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 Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
my cotni2any—.
a. Bottom of Bed—Generally, this is the first (I') inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to: licitlt:lidei)t(ci�towtiofii(.,)rthaii(lovgl:.colii) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer, must
be present for this inspection. With a 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. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other thaii sh-vple excapatim) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and or revocation or suspension of rn license t o o perate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. 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 or consultant
d Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as 12er the
approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligatio
Undersigned Licensed Septic :InsnS taller oday's I)atc)
Installer;
7_11ne-- Pruit) Signed)
Date.... .: P .,,...
TOWN O NORTH ANDOVER
WIRING
PERMIT FOR
�t
:.....�`.............. . .............................
.s.,t,,.. f,.,u...t. r::"aA• 'l i.C.,^'.............................-
w. icar�l tic,dil'Td'c7rlTa 1!!//.
ha,,pe.rtrrds;� �
wiring in the bu 1° ��d .,.. �. �, .................................
al ..l' � s r..:;W 7 i . ............... .I+lorth Andover,Mass.
ELECTRICALINSPEC-r0k
Check #
C) 7 �,> Ad
Est
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04 dR�u ,ti Commonwealth of I'Jassaohusetts Map-Block-Lot
107.A-0076-
-----------------------
Board of Health a Permit No
North Andover
BHP-2008-0178
-----------------------
isSpcwOSEi� F.I. FEB
$250.00
Disposal Works Construction Permit
Pezniission is hereby granted James-Kellett
to(Repair)an Individual Sewage Disposal System.
at No 45-6 SUMMER STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2008-017 Dated September 02,2008
Issued On: Sep-02-2008
------------------- -------------------------------------------
Board of Health
Armlication for Septic Disposal System , � y
TODAY' ATE
%Construction Permit - TOW N OF
*Yr' '""'"""• 'dry# ORTH ANDOVER MA 01845 $ 250.00—Full Repair
$125.00 - Component
SwcHUg�
Important: Application is hereby made for a permit to:
When filling out El 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
to move your ❑ Repair or replace an existing system component--What?
cursor-do not
key the return A. Facility Information
Y
QAddress or Lot#
A bLlf,&_
City/Town
2.- TYPE OF SEPTIC SYSTEM*.
Pump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ 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)(Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
7f' A
Na l e
M C
Address(if different from above)
IN o ` c
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Company
A dress
hA(letrk olr?"
City wn State Zip Code
Telephone Number(Cell Phone#if possibleplease)
4. Designer Information
"I—Ac.A - " (S W err �A
Name Name of Company
?Ds 'W 6;
Address( /y l
Cityrrown State y / Zipf Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
8PIRlication for Septic Disposal System —-----___--——---------
°� Construction Permit - TOWN OF TODAY'S DATE
A I
4-217-E. $ 250.00 -Full Repair
ORTH ANDOVER MA 01845
$126.00 - Component
S CHUS
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Buildinq:XResidential Dwelling orE]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 Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
b issued ued by th' B and of Health.
o s,
a e Date
Appliq i Approved B r'(Board of Health Representative)
o ti'�
A
_�z
9
e 6'Y
N
D aC
p e
pplication Disapproved for the following reasons:
For Office Use Only:
L Fee Attached? Yes(XX No
2. Project Manager OhYgation Fr&M Attached? yes No
J, Pump S
ys ? If so,Attach copy of Electrical Permit Yes No
4. Foundation As-Built?(new construction ronly): yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(Address of Septic SySIC11:1) For plans by
Relative to the application of �/m A�&7a
(Installer's name) And dated
(Original date.
/
—/J.— 0
Dated dK —
f I octay's date) With revisions dated(Las't revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans p1joi to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. 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 Title 5 and the Board of Health kegulations ma result in a $50.00 fine being levied against me and or
my company.
a. Bottom of Bed— Generally, this is the first (1") inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to: healtliclet)t.L�i)t(o)xwviiofn(.)i.-thaiic]oN,er.coLii) from the engineer must
q,_
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a 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. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (oll)er than siviple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done 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 to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. 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.
A Inspection of the sand and stone to be used
c. Final inspection by Board of Health staff or consultant
d, Installation of tank, D-Box,pipes, stone, vent,pump chamber,retaining wall and other
components.
6. 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.
Undersigned Licensed Septic Installer: &__ K(rl"o d a y's [)are)
&22 11
Lant) Signed)
Bate... .......r ..........
Y� 1'-5 14, OF NORTH ANDOVER
04 ' .140 TOWN
oil M [RING
� �RFV
...............
This c;ert,iCis that ......... ................................ . ............
has permission 1C w t'OCAt1
4 .... .�' ..........................
wiring .....
in the k+uik itj; of �. �,:; .................................
at . .f '; .,..: ? 4....:'� ................ .North Andover,Mass-
..........
L:ic.110., .........
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