HomeMy WebLinkAboutHealth Permit # 11/17/2016 Commonwealth of Massachusetts Map-Block-Lot
• 072.00001
BOARD OF HEALTH
Permit No
North Andover BHP-2016-0475--------------------
FEE
$175.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John L. DiVincenzo
to(Repair)an Individual Sewage Disposal System.
at No 73 RIVERVIEW STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2016-047 No emb er 17,2016
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a
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Issued On:Nov-17-2016 BOARD OF HEALTH
Application for Septic Disposal System
' TODAY'S DATE
Construction Permit - TOWN OF
Full Repair
NORTH ANDOVER, MA 01.845 175. 0 Component
Important: Application is hereby made far a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use ❑ Repair or replace an existing on-site sewage disposal system* c
only the tab key 0,R'epair or replace an existing system component—What? '015'r
to move your
cursor-do not
use the return A. Facility Informa ion
key.
Address or Lat# " '
___........ _
City/Town
2.-*TYPE OF SE LTIC SYSTEM*: TOWN OF NOKTFIANDOVER
)�- [:] Pump Gravity(choose one) HEALTH DEPART T
***If pump Wstem, attach copy of electrical permit to application' i
➢ @Conventional System (pipe and stone system) •J
3� ❑ 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)
Y ❑ Pressure Dosed (D-Box Present)S.A.S.
Y ❑ Does the system require an effluent filter? Yes 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)
W11mt is the Make? _....,._,...._._.._--Wbat is the Model.
2. Owner Information
Name
Address if different from abov ) � ���
y
-----------. _..._.....
Ciiy/Town State Zip Code
___----------- __._.._...._........... ....... ....._.....
Email address Telephone Number
3. Installer Information
C'
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
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 _...___..
TODAY'S DATE
Construction Permit - TOWN OF
$3500 -Full Repair NORT H ANDOVER, MA 0184
$175.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: Residential Dwelling or QCornmercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage Isposal s stem in accordance with the provisions of Title 5 of the
Envi o e a Co e, as ell as the Local Subsurface Disposal Regulations for the Town of
No h nd r. 1 nd stand that until a final Certificate of Compliance has been issued by
thi ar of h he installed system is not approved.
j e Dat
icati h Approved" (" d of H, alth Representative)
$" • bard
aiJ )r �
ne� "�-_-_ Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No,_—,
Z. Pro"ect Mana er Ohli ation Foam -clied? Yes- No
3. Pump Sys tem? If so, Attach copy ofElectr •,I Permit Yes------------. No
Applican t received copy of
"Electrical Inspection Notes for Septic Systems ' Yes No
Handout?
O
f roialletter• all a erworkreceived
Yes N
4. Revteived app , p p
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:
For plans by
(Address of septic system) (Engincer)
Relative to the application of a 2
1 (Installer's name) And dated (Ortginal date
Dated 2 14� )
/Yoday's date) — With revisions dated(Last revised date)
I understand the following obligations for management of this project:
I. As the installer, I am obligated to obtain all permits and Board of Health approved plans prfor to
performing any work on a site. I must have the annroved 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 apl?hcable 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 mav result in a $50.00 fine b6i levied against rue and/or
My Compafl�L.
a. Bottom of Be —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: healthdept@notthandoverma.gov) from the engineer inust 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 sihIple excanalion) 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 ir:t 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 tan]<, D-Box,pipes, stone, vent,pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solelv resnonsiblc for the installation of the system as per the
approved plans. No instructions by the,home-owner. general contractor or any other persons shall absolve
me of this obligation.
_
Undersigned I.,icensed Septic Installer: Sda 's Da
Jo �o L w' c e IU2-,C-'
— J/Jr 7�
(Name-Print Nr,/-Signed)