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HomeMy WebLinkAboutHealth Permit # 8/21/2017 (2) Application for Sefic Disposal System /`�r 17 C©nstructib Permit - TOWNOF TooAY's DATA NORTH AN,—DOVEMA 01845 $250 6-.I 1!)-Full Rep1. nt � :611-Component Application is hereby made for a permit to: F Construct a new on-site sewage disposal system* El Repair or replace an existing on sewage disposal`system* ► JA Rke-pair or,replace an existing system component-What? A. Facility Information. -���- Address or Lot# ` Cityrrown 2.-*TYPE 4F SEPTIC SYSTEM`: ➢ ❑ Pump ravity(choose one) 'if pump system, attach copy of electrical permit to application*** nventionai System (pipe and stone system) ➢ ❑Infiltrator or Blodiffuser(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-Box Present)S.A.S. ➢ ❑ Does the system require an effluent fitter? Yes No If yes, does plan specify make and model of fitter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Mode§ 2. Owner Information Name Address(if different from ab ve) _- -- V,„f A V,el? .. _ Cityfrown State Zip Code Telephone Number 3. Installer Information Name Name of Comppn AMON ENTERPT11 8,r_ ,live. Address f� ANDOVER,MA ol w o � �?� /6'21��{.. f" 1 �L'� Cityrrown. State Zip Code Telephone Number(Cell Picone#if possible please) 4. Designerinformration Name Name of Company - Address 67,iii own State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 w`RY`�w Awfloation..for �� t�C DjS: v�ai s ern MT Constru0!0-n an, It Wars pAT * '' .:....� '' ATT4 A— � MA $,zea oo �Ull Repair 01845 . - --- Component PAGE 2 Of 2 R A. Fadility.Information:contiinitaed �.... ..�. S. Type, Bulldin : sidentlal.Dwellin . , eg or❑Commerclal B. Agreement The undersigned agrees to ensure the construotlon and maintenance of the afore>descrlbeId on-site sewage disposal system.In accordance with#he.provislons of Tltle 3 of the Envlronnmental Code, as,well as the 46ca/Subsurfaca Dlsodsal Regulatlons for the Town of North Andover, and not to p/ace;the system M operatlotr untli a Cortlflcate of Compllance;has r been issued y this Board of Health. Name Date -A I do 'Apprdva# � oard fKealth Representative) qy Application Disapproved.for the following reasons; For Office Use Only: 1. ' Pec Atta,cbrW Yes Na 2.• Ptalectlllwaget 0.b gad0j7.ForniAtt=6b d? Yes " )V tem_? IfsO4Atta coPVafF,lcctrrcalPcrr»z`t' : acs ,row 4. Fautrda ou tr As-Bur'1t?phew constructio&ronly): (Samescale as apptayedpla ) 5. FlootPlax s?'(7e.w construction'only): Appif Hdn•for,,rgposat�y',stbt-10onstructicriPermft Ruoe2ort s��`rc•s�s�s�,��i.�nr.�r' .�tr �'�a��s�x� t�;��'��r.,�cr�,�rcnvs Aa fg;r 4otdi struto"f0g•'thwReptic iryste m for thaTrape d'a: (yid ofaepttc igrte�u} 6r pian by ....w.- ReUtl"to tt gpptmdm of (Nioullces qmm htul daW Dttrcaster.ku d � ��y 1 � ' a t A) mm moat dated W dim) I tsndentattd the fonowing OBIWAtions for Baa cat of fs P._. sect: 1. .As the iaataJleti I am.ob4ptcd i-a obWa tff pe m itr and Bond o e alth sppt ved phmpez oa apt Ag aap:wolk aa3-it edtr:: Z. At�t :f.z:i'ustiaIIfv astfta$ cow 4oia pemost not ft4oc b tied w th stay ce:npiq n h� cm sad&0 apatrm r�ot-trgdy,for t '3tem t�e•slra}Lh�,�?p1�c�rbIo. .. �'• , �,t � �I'sttx�rcpcd�v.hsev�c� �y � p�a���t'hc.�ppllgrb�eioa�tetssts Anif.-Aali U- LMY a b cidertrioyt t: =dou i ut c4cCettot have to bri preyt it; b. :mia►�t Fatarcdt; s ' �acn far -tib,ebc. . � ' i o �OIfi"(c�:e e•�I� from the rapiers m�s� ba#tibaiittrxlxc.Boiud of •Y ,s$4t: t fcarapect dma`I�stliriut hrspr i<fctr be q and shh:to . ' 'sauae�pt .tti�or3e�iti��o�ii�'b�ost., • • : . •.• •• ' - - must s+ gvgt msp=an. w*UgedWg-jjs"lttc: Tit cc daci not 4, As-the iptdim.T uad d tint ft%=lbi M6104 otos)041 fopked 6a rrztapiete the t at sz a t e spstEr i fr #k ie e¢xppJ o t, :hiat�n on. Q=c3ftf 11-4- PIP .. . tete h;at tc �r n c#rr�tniti ' tI s>ro� c ami idut3i re pf tft &Hcwlfrg ccaitmct7icn, De��tla�tb�rf.�Ct�,pr,�prrrfegnt�itaft�•ra,da�r,�:rvbc�rr�e•�c�ec� - - ' . bIsrsp �€oa t re"4nWd rrdrd erre qtr be Med . � 'Ffasl�nrapetrr,*o�rhyBa�tr�:�fe�rlrhertpA`'oraosssuh�t�• . d adfoxr of D-Vov ,s pvj�r pAia.R fiber,&mwvm►8nd other-cmund thot Lem MI* . mond. / Xlnde�d'�c.�ted$t�ttc,Is�� � ., • �Q�13� � �—/�—!