HomeMy WebLinkAboutApplication - 31 JAY ROAD 8/30/2017 7 " q— A
losal Svstem
Septic Disp
Application for Se TODAY'S DATE
it — TOWN OF
Construction Perm Full Repair
NORTH ANDOVER MA 01845 $ 25.00 Com ponent
Important: Application is hereby madefor gto.
- rmit�
When filling out n Construct a new on-site sewage disposal system*
forms on the
computer,use 0-kepair or replace an existing on-site sewage disposal system"
only the tab key F1 Repair or replace an existing system component–What?
to move your
cursor-do not
use the return A. Facility Information
key.
Address or Lot# -31
V 011b
2.--*TYPE OF SEPTIC SYSTEM, '[OWN OF NORT11ANDOVER
> Ump, ❑Gravity{choose one [IFEAUR i DEFIARTMENT
***If pump system, attach copy of electrical permit to application***
> E]Conventional System (pipe and stone system)
> [E]Tnfiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
> rl Pressure Distribution S.A.S.(No D-Box)
> F1 Pressure Dosed (D-Box Present)S.A.S.
> r-1 Does the system require an effluent filter? Yes—LI-f No
If yes, does plan specify make and model of filter? YES =(no further info. needed)
NO =(Installer must specify brand of filter before DWG issuance)
"at is the Make?
2. Owner Information
Address(if differen#from above)
Zip Co-de
-6t—yrrown State
'Te—lephone Number
3. Installer Information
Name of ComPa
Name WYATECON ENTERPRISES,, INC.
ANDOVER,MA 0-1810
Address
Tityr—rown State Zip Code
d�
Telephone Number(Cell Phone#Wpossible please)
4. Designer Information
-Wa—me – Name of Company
-
-Address
Zip Code
7&i7ty/f own State
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Ap�plipa�ion,.for Septic Dispo:�at -system
����i.,�,• p'Const•ruCtion �Pa.rmit TO V O zopArs DATE -
--
-O:RT1401845 $.230.66-Pull Repair
OV R� .MA
sICHU -. - - - .$125.00,-.Component
PAGE 2OF2
A. Faci[ity•Information continued....
6. IT
We- Building: EKesidential Dwelling or OCommercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system In accordance with the provlslons of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulatlons for the Town of
Y North Andover, and Trot to place the system iii operation until a Certificate of Compliance has
been issued Is Board of Healf(r.
Name Dete
Appll 1 �Appr• day: (Board of Health RepreserrtativeJ
Name date
Application Disapprovedl for the following reasons:
For Offee Use Only:
I. -Fee Attached?: Yes V/ ' No
2. Projcctlflartager Oblrgatrau Form Attaebed� Yes ATS
^.
Ifso.,Attaah=V afElectrlcal Fermr_'t i Yes Na
4. Far=dan'o-rAs Bur' R(new construction,ronly): Yes No
(Same scale as approved plan)
A FloorFlws?(new construction'only); �'cs� No
ApplfCattbndor•p(spp3al yster)r. cnstruct�rrri Permtt Daae 7 cir7
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