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HomeMy WebLinkAboutHealth Permit # 12/28/2016 • Commonwealth of Massachusetts Map-Block-Lot 038.00060 BOARD OF HEALTH P Permit Na North Andover BHP-2016-0496 FEE $350.00 PERMITDISPOSAL WORKS CONSTRUCTION Permission is hereby granted Robert K. Daigle to(Upgrade)an Individual Sewage Disposal System. at No $08 JtJ1INSON STREET as shown on the application for Disposal Works Construction Permit No. BI-IP-2016-049 Dated. December 28, 2016 BOARD OhHEAY,"1'H Issued On: Dec-2&-2O1Ei P 1� Application for Septic Disposal System ATF Construction Permit — TOWN OF T017AY'S $350. Full Repair NORTH DOVE A 01845 77.1000_Component Important: Application is hereby made for a permit to: when filling out ❑ Construct a new on-site sewage disposal system* farms on the computer,use -[Repair or replace an existing on-site sewage disposal system* 1^t only the tab key to move your © t? Repair or replace an existing system component—What? cursor-do not use the return A. Facility Information key. ��t ._. Address or Lot# ,�, C .�.... _ HEAit71 FRARt __._ - ENT City/Yawn I e 1�'.^✓' 2.-*TYPE OF SEPTIC SYSTEM*: Y ❑ Pump ❑ Gravity(choose one) ***If pumps tem, attach copy of electrical permit to application*** Y [Conventional System (pipe and stone system) > ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.) Y ❑ Pressure Distribution S.A.S.(No D-Box) > ❑ Pressure Dosed(D-Box Present)S.A.S. Y ❑ 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) W115at is tlae Make? What is the Madel.] 2. Owner rm to ion NpQ r ..__.... .. _....._._- -- Address(if d' erent from above) _ 1 ' „4?— _ ----- `, ............... CitylTawn Stat / ,7 � I� � J` �Zup Code _. .___,,,,,,_---------_.._._a.._.__._._.. .............................._....__._.___...._ Email address Telephone Number 3. Installer Information , Name _. Name of Company Addr ss City/Town State Zip Code j Telephone Number(Cell Phone#if possible please) 4. Designer Information Name r Name of Company Aclojess City/Town StateZip od Telephone Number(Best#to Reach Application for Disposal System Construction Permit-Page 1 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of sceptic system) For plans hY �. 071ngineer) Relative to the application ofJ (Installer's name) And dated (Original ate Dated t 1 arc: 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 prior to performing any work on a site. I must have the annroved plans and the permit on when any 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 is not 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 requesting an inspection without completion of the items in accordance with Title 5 and the Board of Healthket;ulations may result in a $50.00 fine being;levied against me and/or my cccompan a. Bottom of Bed— Generally, this is the first (1") inspection unless there is a retaining wall,which should be clone 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, etc. As--built of verbal OIC (or e-mail to: healthdept(a)northandoverma.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection tithe. 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 must 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 s irrl)le exav)alion)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that wadi done loy othersunlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation of suspension of my license to operate in the Town of North Andover, significant fines to all persons involved 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 readied, b. Inspection of the sand and stone to be used c. Final inspection by Board ofHealth staff or consultant. d. Installation oftanlc, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, ene al contractor, or any_other persons shall absolve me of this obligation. Undersigned Licensed Se tic Installer: foda is Date ame— tint (Name—4 igne.