HomeMy WebLinkAboutHealth Permit # 7/31/2017 (2) Application for Septic Disposal System
TODAY'S DATE
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 E] Construct a new on-site sewage disposal system*
forms on the
computer,use F1 R Ir or replace an existing on-site sewage disposal system*
only the tab key A L S 1�1_
to move your VRepair or replace an existing system component—What?
—
cursor-do not
use the return A. Facility Intormatiom
key. %
("I M\
Address or Lot'#
..................
-N-4
City/Town
2.-*TYPE OF SEE210 SYSTEM
> El Pump ETGravity(choose one)
***If pump stem, attach copy of electrical permit to application"*
> J Conventional System (pipe and stone system)
> ❑ Infiltrator or Blocliffuser(Gravet-Less)(Attach a copy of your certification to install this type of system.)
> ❑ Pressure Distribution S.A.S.(No D-Box)
> F1 Pressure Dosed(D-Box Present)S.A.S.
> n Does the system require an effluent filter? Yes No_k��7
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 the Make? 1 V45 a t is the Moder
2. Owner Information
-e
. ...........
Name
AddreA(if different m
,�a b/o
City/TdTNn State Zip Code
_...._._..__------.._..........___.._--._..__.--
Email
........................
Email address Telephone Number
3. Install r Informatim
�-e
L .. . .. ............................
/,a)
Na
Name of Company
---------------------------------
Addr s,
—.6. — ——--------
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
_Name - ---------- Name of Company
State Zip Code
Tb lophonoNumber(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
'D A oel")
Application for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF $350.00-Full Repair
NORTH ANDOVE A 01845 $175.00 -Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: pKes-idential Dwelling or FjCornrnercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage osal system in accordance with the provisions of Title 5 of the
vi n en I as 11 as the Local Subsurface Disposal Regulations for the Town of
NJ rt do and that until a final Certificate of Compliance has been issued by
t t
h
I B rd f It e installed system is not approved.
Date//—L4
Applic n Appr v oard of Health Representativr
3
N e
Applicati' n Disapproved for the following reasons:
For Office Use Only: L/
1. Fee Attached? Yes-- No
2. PtojectManager OhligatioiiForm AttachedP Yes No—
3. pun) )S
ystem? If so,Attach copy of ElectikaLl-'etinit Yes No
Applica,ot,received copy of L
"Electdcal Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed appfovallettei, all paperwork i-eceived? Yes No
Missing
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
G. Moor Platis?(new construction only): Yes— No
Application for Disposal System Construction Permit-Page 2 of 2
RECEIVED
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGXr 10N�S 3 -17,(111
As the North ndover licensed installer forthe construction for the septic system for the proNORTH ANDOVF-R
ie RUN DEpARTMENT
(Address of septic syster-1) For plans by (Engineer)
Relative to the application of
(Installer's name) And dated
(Uriginal date)
Dated
(Yoday'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 Health approved plans ptior to
perfonning any work on a site. I must have the g.)proved plans and the permit on site when_arty_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 isnot 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 gequesfigg_An,inst�ection without completion of the items in accordance
with'Fitle 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
MY-9-0-r—ap.any-,
a. Bottom of Bed—Generally, this is the first (1") inspection unless there is aretaining 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, et:c.
As-built of verbal OK (or e-mail to: healthdept@northatidoverina.gov) 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 in-List 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 sivole excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
r
understand that work done by others unlicensed to install sepdg_���_Andover can constitute
reasons for denial of the system and/or revocation O:r-9usp—c)isi—(o-....n-...--o-f my license to operate in the Town of
North Andover, significant fines to all psirsops inyglved.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 xe-acbed.
b. Inspection of the sand and stone to be used,
c. Final inspection by Boa-td ofI-Jealth staff or consultant.
d. Installation of tank,D-Box,pipes, stone, vent,pump chamber, retaining wall and other.
con1ponents,
6. As the installer, I-understand that I am solelv resoonsible for the installation of the systern as per the
approved plans. No instructions bv the laomc,Aqr, Pen nal contractor. or an other_persons sball absolve
me of this obligation.
-Undersigned Licensed Septic Installer: (roS te)
'():%Ye'
Name an}
, Sign"e'd)