HomeMy WebLinkAboutHealth Permit # 9/8/2016 r
Commonwealth of Massachusetts Map-Block-Lot
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BOARD OF HEALTH
Permit No
North Andover BHP-2016-0275
P.I. __ FEE
F.I. $350.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Dave Ma hard
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p
to(Construct)an Individual Sewage Disposal System.
at No 51 WELLINGTON WAY
as shown on the application for Disposal Works Construction Permit No. BHP-2016-02 DMA September 08,2016
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Issued On: Sep-08-2016 BOARD OF HEALTH
Application for Septic Dispo S�I
.. � TODAY'S DATE
Construction Permit - TOWN OF
�1 CRTH N OVER. MA 01845 Component
Important: Application is hereby made fora permit to:
When filling out RITonstruct 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 ❑ Repair or replace an existing system component—What?
to move your
cursor-do not
use the return A. Facility Information
trey. JW
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Address or Lot#
City/Town _
2.-*TYPE OF SEPTIC SYSTEM*:
Y E] *** ��
Pump ravit choose one) b . o � O°��'
***If pump system, attach copy of electrical permit to application
Y RgTonventional System (pipe and stone system) TOWN C)F NORTH AN[ A/E'['�
1� ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this WA � C
❑ Pressure Distribution S.A.S.(No D-Box)
❑ Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
ff yes, does plan specify make and model of filter? YES =(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make? What is the ModelP__m______---------
2. Owner Information
........ .....
Name
Address(if different fro above)
ity/Yawn State Zip Code
Ema address Telephone Number
3. Installer Information
..._.- _
Name Name of mpany
Address
-------- _
City/Town State Zi p Code
-'.__ 2 a
Telephone Number(cell Phone#if possible please)
4. Designer Information
w CI
ame�v Name of Company
Address
9.11_ i A� _._a„_.........__.._ A .f°.
City/Town State Zip Code
-
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for Septic i sposaj stem
TODAY'S DATE
Construction Permit — TOWN OF
$350.00-Full Repair
t
NORTH ANDOVER, MA 0184,E $175.00-component �
PAGE 2OF2
A. Facility Information continued....
i
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 Health, the installed systA is not approved.
Name Date
App` ion Ap o y: (Board of Health Representative).................--- 9 / —
a Date
Alicati n Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes`", No
2. ProjectManagee Obligation Form Attaclxed? Yes No
3. Punt S,�ern? If so,Attach cot2V ofE"lectrical Permit Yes _ No
Applicant received copy of
"MectricalInspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed approvallettet; all papeiwoik received.? Yes No
MISSInQ'.�
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:
IY5p1 Ale III
(Address of septic system) For plans by �:ti+.�f�w-
{Engineer)
Relative to the application of ,.e
(Installer's na e) And dated — y r /((l'
(Original date)
Dated Z-0 e
(I'n ay s ate 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 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 rMuesting 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 a ainst 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: healthdept Qtownofnorthandover.com) 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 b others unlicensed to install septic s stems in North Andover can constitute
reasons for denial of the system and or revocation or suspension of my license tooperate 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 per the
a1212roved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date) G Zo
(Name—Print (Name—Signed)