HomeMy WebLinkAboutHealth Permit # 6/6/2016 Commonwealth of Massachusetts 104. O068Lot
• �r7 xn r • 104.60068
•
BOARD OF HEALTH Permit No
•
BHP-2016-01196
North Andover
FEE
$350.00
DISPOSAL WORKS CONSTRUCTION PERMIT r
Permission is hereby granted Dean Dynan----------------- - -----------------
- - - - --------------------------------=------------ - -
to{Upgrade}an individual Sewage Disposal System.
atNo 24 DEER MEADOW ROAD ----------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2016-019 Dated June 06,2016 t�
issued On: Tun-(?6-2016 `BOARD Off'�-IEAL��I-��
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/DA�IDAT
Application for Septic Disposal System
E
Construction Permit - TOWN OF
$350.00 -Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
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 epair 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. F Cllity Information
key. �`_ t®.
r
Address or Lot#
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
Y- ❑ Pump ❑ Gravity(choose one)
***lf pump system, attach copy of electrical permit to application***
conventional System (pipe and stone system)
Y ❑ 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)
> l] Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Ye 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 is ance)
� L
Wlr�rt is the Make? ^���+ What is#lie Model?_�-.
2. Owner Information
...
Na e
Cf
Address(if different from a ove)
AVe
V r' 1
City/Town State Zip de
Email address Telephone Number
i
I Installer Information
i
Name . t•� Name of Company
�" `!
ti 7
r
qJ&Address
City/Town State Zip Code
Telephone Number(Cell Phone#ififlossible please)
4. Designer Information
Nine, �� � , �, Name of Company
-- — -
droas�s
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 �
p v
„ - TC7 AY'
Construction Permit - TOWN OF
$350.00- Full Repair
NORTH ANDOVER. MA 01845 $175.00-Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: Mesidential 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. 1 understand that until a final Certificate of Compliance has been issued by
thi obrd of Health, h tailed system is not approved.
D
game
- _. .. at
'�Jicaon pp r` y: B al of Health Representative
Name Date
Application Disapprov d for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
4\
2. Project Manager Ohligation Form Attached? `�ti Yes- J No
3. Purnp System? If so,Attach cape ofElecttical Permit Yes,,.__ No
Applicant received copy of
"Electrical.Inspection Notes for Septic Systems" es -__,_. No
Handout?
4. Reviewed approval letter, all papetwoik 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:
(Address of septic systern) For plans by ,� ��`"`� �✓ ��f'�'�'�l c✓.h/�r
Relative to the application of Oea d"I" V? "2G
(Installer's name) And dated '
t r l;tnal ito
Dated �
c7c:ay s date) With revisions dated
(Last 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 I"lealth approved plans .rior 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 fide 5 and the Board of Health lie ulations 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 OIL (or e-mail to: liealth.de~ttt i)ttownoftiorthatidcrvcr.cotn) 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 r`hfan simple exwpatioii) 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, 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 per the
approved plans No instructions by the homeowner.,general contractor, or agy other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Poday's Date)
atne— Print)
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