HomeMy WebLinkAboutHealth Permit # 6/30/2017 Application for Septic Disposal $Vstem
Construction Permit — TOWN OF TODAYS DATE
$250.00-Full Repair
NORTH ANDOVER, MA 01845 $126.00-Component
Application Is hereby made for a permit to:
Construct a now on-site sewage disposal system*
❑7p R air or replace an existing on-site sewage disposal system*
e air or replace an existing system component-What? 4 rz-
A. Facility Information
4/11
p A'
Address or Lot#
Cityrrown
2.-*TYPE OF SEPTI.SYSTEM*:
> 0 Pump [EMravity(choose one)
***If pump system attach copy of efectricalpennit to application—
> [3�6onventional System (pipe and stone system)
> E]Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
> [] Pressure Distribution S.A.B.(No D-Box)
> E] Pressure Dosed(D-Box Present)S.A.S.
> E] Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES=(no further info. needed)
NO=(installer must specify brand of Miter before DWC issuance)
What is the Make? What is thcmodch�_
2. Owner Information
Name
Address(if different from above)
Cityrrown State Zip Code
3 1�7
Telephone Number
3. Installer Information
Name Name of Company
Ar //,I- tw
Address I I I ARC, F11TIMSEr3l INC.
1L.LA fjOAD
ANDO
CityrTown State7 'Zip o e
Telephone Number(Celt Phone#if possible please)
4. Designer Infonyration
----------------
Name V Name of Company
Address A
City/Town -State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
aRrN
Aplipa# o�n..for Sp_t�c Disposal Sys#ern
e 0r��t
4 %G.vnSfry2tidn Perrrrtf 1'0 O 70DAr5 DATE
,�• "_�R'I H �►NDbVER, .MA o 0o T Ful1$epair
�..�.s — 01845Z .av.co
S��N� — $ mpor:ent
PAGE 2 OF 2
A. Faciii tnformaflo.n con#inued,...
S. ZEpeof Buiidin esidential Dwelling or❑Commerclal
B. Agreement
The undersigned agrees to ensure the constructlon 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 Regulatlons for the Town of
North Andover, and not to place the system Irl operation untl!a Certificate of Compliance has
been issued this BMW of Health.
Na me Dgte YY
Application Approved By: (Board of Health Representative)
Name Bate
Application Disapproved,for the following reasons:`
For Office Use Only:
L "Fee Attachcd? Yes No
2,• PmlectAfimaget Obligation Form Attacbed? Yes No
3.: ? Ifsoj� e�_ i �: `cal 'rmit' Yes No
4. Found.'dO rAs Built?(hew construction ronly); Yes No
(Same sere as apptoyedplaa)
j A FlootPlaws?'(hew-construction'only); Yes No
o-
plFcatlan'for,t7lsposat Syste�ii^•tronstroctten permit;Reae 2 of P
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I undcn=d the following 04gationa f0t monag=ent of0b pra-r
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