HomeMy WebLinkAboutHealth Permit # 11/7/2016 Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
'-Full Repair
NORTH ANDOVER, MA 01845 00 Mponent
Application is hereby made for a permit to:
❑Construct a new on-site sewage disposal system*
Repair or replace an existing on-site sewage disposal system*
repair or replace an existing system component—What? 0;1 A.—o
A. Facility Information
Address or Lot# _2)& AA/,
___ Ab A-4- A14,
Cityrrown
--------
2.-*TYPE OF SEPTIC STEM :
> r1Pump [3'0-ravity(choose one) NOV U '/ N16
"*If pump system, attach copy of electrical permit to application**"
> E]Conventional System (pipe and stone system) J INUR
OM&F I "TH ANDOVER'
> E] Infiltrator or Blodiffuser(Gravel-Less) (Attach a copy of your certification to in 4�p/qfMWnj
> E]Pressure Distribution S.A.S.(No D-Box)
> 0 Pressure Dosed(D-Box Present)S.A.S.
> E] Does the system require an effluent filter? Yes No L—'_
If yes, does plan specify make and model of filter.? YES=(no further info. needed)
NO=(installer must specify brand of filter before DIMC issuance)
Whatis the Make? What is the Modci�___
2. Owner Information
_A,9 /I/t/
Name
_3
Address(if different from above) mm
City/Town State Zip Code
Telephone Number
3. Installer Information
E3�# fe
Name Name ofCorn n
1.4 PROCON r-.NTr7irnise--,, INC.
Address
ANDOVER, IVIA()I i3l
Cityrrown State Zip Code
Telephone Number(Cell Phone#it'possible Please)
4. Designer Information
Name Name of Company
Address
CityfFown State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
MTN Aplipaion..for Septic Dspysatystern ' =
r�i
- *Gonst ruction -P rrrrit "' 1 TODAY'S DATE
* �. •'rl $.250'.1)0�-Full Repair
�+++..•" _ OR T- 14 AN I�b��t� MA 01,845
Sa�CHU• $'125.00-Component
PA►GP 2 OF 2
A. Fadltlty.lnfarmatlo.n confinued....
5. Type,of Building: esldential Dwelling mor E3Comercial
B. Agreement
The underslgned agrees to ensure the construction and maintenance of the afore-descrlbed
on-site sewage disposal system In accardance with the provisions of Title 5 of the
Env/ronmental Code,as we/las the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system 1n operatfon until a Certificate of Compllahce has
Board of Health.
been issued b !s Bam�
Name _._..
Date
4Appllatlon
Approve" � : (Board of Health Representative)
Date
D approved.for the following reasons:"
For Offiee Use ClOnlu;
1 "Fee Attached? Yes No
2.. PtajectMartagget Obligation Fon7z ttacbedP Yes
3.: Pura $JWem? Ifso)Attach cQQg afLc'I��i P ,No
4. Foundat(onAs Bullt.?(hew constructloh-ronly); Yes No
(Same scale as spptayedplan) "`
5. FlaatPlarrs?(hew constructlon'only). No
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