HomeMy WebLinkAboutHealth Permit # 8/9/2017 Application E;'�`�It1C Disp sa.i Sststem
catiOn forI' MM
�-
Construction;Permlt -- TOWN OF Toloars DATE
NORTH ANDOVER MA 01845 $250:00^—Full Repair
:80-Component
Application Is herebv made for a permit to:
0 Construct a new on-site sewage disposal system*
❑Repair or replace an existing on-site sewage disposal'system*
apair or replace p ace an existing system component What?
co
0J(1_1/ T'X'Q.. �. - %, e r„,A _4 0.._ r a,j�.
A. Facility Information
Address or Lot#
u,
Cityfrown
2.-*TYPE OF SEP 1C SYSTEM*:- O\A
Y ❑ Pump ffGravity(choose one) Cly PP��
***!f pump sys , , attach copy of electrical permit to application*”`
➢ onventional System (pipe and stone system)
➢ ❑ Infiltrator or Biod'rffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
➢ ❑ Pressure Distribution S.A.S.(No D-Box)
➢ ❑ Pressure Dosed(D-Bax Present)S.A.S.
➢ ❑ 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)
What is thcMake? What is the Mode& __
2. Owner Information
Name
Address(if different from above)
Al 41
City/Town State Zip Code
Telephone Number
3. Installer Information
LCN FNT�'ii"'fvsr:::,
Name Name of Com
Ali I i it�A(�l A l�,INC,
Address �, u
City/Town, State � ZiRdel
Telephone Number(Cell Phone#ifpossible please)
4. Desigginer1rilformation
Name _ Name of Company
Address
CityCTawn State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
c aNrH�y Applicati'o tfor Septic Disposal System '
ti TODAY'S DATE
C.canst�ruction P�rmrit - T(J►. . �OF
«. � OR3NIbt 01845 $. so.00�-Full Repair
S CRUS `' ,�` sm.00.-Component
PAGE 2 of 2
A. Fad111ty•Inf6rmat1o.n continued,..,
S. T e'of Buttdin esidential Dwelling or Commercial
- Yp � g
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-des"cribed
on-slte sewage dlsposal 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, and not to place the'system In operation until a Certificate of Compliance has
been Issued b this Board of Health.
Name We
p�lpatl9p ApproverB ( oard olealth Representative)
M' tl
w Date
Application Disapproved,for the following reasons:
For Office Use 0Vjy.-
1. -Fee Attached? Yes No
2, PtojcctAffirdaget Obligation Form Attached? No
3.: Ps rn o=? Ifso)Attach co�py afElectn ral Pernr,�t �'es �
• No
4. Foundatr`onAs Burltr?(hew constructlo►1,ronly), Yes• NO
(Same scale as apptovedplan) ;
5. FWrFAans?(hew constructlon•only).. N
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