HomeMy WebLinkAboutHealth Permit # 4/19/2016 • � Commonwealth of Massachusetts Map-Block-Lot
��•. 105.00022
�I y, BOARD OF HEALTH Permit No
North Andover BHP-2016-0084
$350.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Jesse T. Warren
to(Construct)an Individual Sewage Disposal System.
at No 602 BOXFORD STREET {-:--=___{-____a,
-------------------------------- ----------------------------------- ----------------- ------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2016-008 Dated April 19,f2016
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Issued On:Apr-19-2016 BOARD OF HEALTH
E
Application for Septic Disposal System, " /) �. . C Uf
T �-�
Construction Permit - 'S'O'WN OF
NORTH ANDOVER., MA 01845 $1:7 . -Go�p�;;
Important: Application is hereby made for a permit to:
When(fllling 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
to move your E] Repair or replace an existing system component--What?
cursor-do not
use the return A. Facility Information
key. 602.
Address or Lot#
!ab ..._._..._.__..._._�...,.q..__ .. -...........
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
Y ❑ Pump EBOravity(choose one)
***If pump system, attach copy of electrical permit to application***
Y ®Conventional System (pipe and stone system)
> E infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
Y ❑ Pressure Distribution S.A.S.(No D-Box)
> ❑ Pressure Dosed (D-Box Present)S.A.S.
Y ❑ Does the system require an effluent filter? Yes l''� No
if yes, does plan specify make and model of filter? YES =(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
ItIhatis the Make? 74; Whatis the Model?
2. Owner Information
Name
—5 c,sf, - / /!) 1,ek � ---------------
' 4 V Address(if different from above)
--
City/Town State Zip Code
Email address Telephone Number
3. Installer Information /
Name Name of Company
Address
City/Town Stale -9 7 g 3,.7, S_ /C ` 1
Telephone Number(Cell Phone#if possible please)
4. I"qn
)I er Information
Name Name of Company
��S' G✓ems u7.r✓ ` % _ — .................
Address
City/Town State - Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for Septic Disposal System _._.
• Construction Permit ® TOWN W ,LEI OF TODAY'S DATE
$350.00- Full Repair
NORTH ANDOVER. MA 01845 $175.00-Component
PAGE 2OF2
A. Facility Information continued.....
5. Type of Building: esidential 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. I understand that until a final Certificate of Compliance has been issued by
this Board of Ith, the installed system is not approved.
2 6
Name Date
ca i Appro a y: and f a h Representati )
Name — Date
Application Disapproved for the following reasons:
For Office Use Only.
1. Fee Attaclied? Yes No
2. Project Matta Obligation Form Attaclied? Yeses/ No
3. Putnp S sy tam? If so,Attac y ofEleetircal Pannit Yes No
Applicant received copy of
"E lectrlcalInspcctron Notes for Septt " sterns" Yes No__....._._.
Handout?
4. Reviewed approvalletter, all papertivork received? Yes/ No
Missing:
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
G. 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:
6,3-2- ?_?.X (r('d <z
(Mdress of septic systeni) For plans by r I'S rl� i
Relative to the application of
(Installer's nanic) And dated A.
Dated (Origit il date
& '3//5--
(1'oday's date) With revisions dated
(Last revised da(c)
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 p6or to
performing any work on a site. I in-List have the a1212roycd plans and the pertnit 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
1 U1 company
a. Bottom of Bed Generally, this is the first(15) inspection unless there is a retaining wall,which
should be done first. 'I'he 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: lic,,tlttidct)t(ii),t�owiiofi-iortliandover.coiii) 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 than simple 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.
b. Inspection of the sand and stone to be used,
c. Final inspection by Board of Health staff or consultant.
d. Installation of tame, D-Box,pipes, stone, vent,pump chamber, retaining wall 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
the of this obligation.
Undersigned Licensed Septic Installer: (I'oday's Date)
(Name—Print) 7acne ergrned)