HomeMy WebLinkAboutHealth Permit # 9/12/2017 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 El Construct a new on-site sewage disposal system* RECEIVED
forms on the I
computer,use Repair or replace an existing on-site sewage disposal system*
only the tab key SEP 12 2017
to move your El Repair or replace an existing system component-What?
cursor-do not TOWN OF NORTH ANDOVER
use the return A. Facility Information HEALTH DEPARTMENT
key.
Address or Lot#
--------------- .......
--"—
city),rown
rein 2.-*TYPE OF SEPTIC SYSTEM*:
> F1 Pump Gravity(choose one)
ttSpump stem, atta h copy of electrical permit to application'
> Conventional System (pipe and stone system)
> Ej Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
n Pressure Distribution S.A.S.(No D-Box)
> F1 Pressure Dosed (D-Box Presont)S.A.S.
> 0 Does the system require an effluent filter? Yes X 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)
U'/ba t is tile Make? If/Ija t is t1i e Mode]P
2. Owner Information
("J ...............
Name
gl e tw -—--------------
Address(if different from above)
-M, A - --------
City/Town - State Zip Code
---- .......
Email addresS Telephone Number
3. Installer Information
I&
Name Name of Company
Addr s
dit" State Zip Code
y/V1
Telephone Number(Cell Phone#if possible please)
4. Desi 'r-'sor
_qner Information
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0 A
.--- It-' _' ____
Narnel -e- '___'r Name of Company
el
474��
Add7s
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,4 4,10-1V
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City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page I of 2
J//r'
Application for Septic Disposal System
T06AVS DATE
Construction Permit - TOWN OF $350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building:jOkesidential Dwelling or RCommercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. I understand that until a final Certificate of Compliance has beet)issued by
this,Board of Health, the inst led ystem is not approved.
7p 4, �
Na Dat
Application Approved By: (Board of Health Representative)
14am'e_ Date
Application Disapproved for the following reasons:
For Office Use Only:
1. FeeAttacIjedP Yes a No
2. Project Manager Obligation Form Attached? Ye No
3. Pump System? If so,Attach copy ofElectrical Permit Yes No
App,licant.received copy of"
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewcdapproi-dllettej, allpapet-work-received? Yes i No_
Missing;
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
G. Floor Plans?(new construction only). Yes No
Application for Disposal System Construction Permit-Page 2 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 septic system) For plans by
(Engineer)
Relative to the application of
{Installer's name) And datedt�j,,-/- 3 Z,C>1
-y rigina ate
Dated -Poll ! _ �--
{ _o ay s ate With revisions dated
(Last re-6sed 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 mist have the approved plans and the pers-lit on site when gay 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 requited to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an ins ection without completion.of the items in accordance
with Title 5 and the Board of Health Regulationsmay result in a$50.00 fine being levied against me and/ox
xray com an .
a. Bottom of Bed—Generally, this is the first (1'� inspection unless there is a retaining 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, etc.
As-built of verbal OIC(or e-mail to: healthdept@noxthandoverma.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 roust 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,rivaple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work doge by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of m license tooperate 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. Detetmination that the proper elevation of the excavation has been reached.
b. Inspection of the snndand stone to be used.
e, Final inspection by Board of Health staff or consultant.
d Installation of tank,D-Box,pipes, stone, vent,pump ehaxnber, xeta.ining wall and other
components.
6. As the installer,, I understand that I am solely responsible for the installation of the system as pet the
approvedp'lans. No instructions by the homeowner,general contractor, or any other persons shall absolve
me of this obligation.
Undersigned.Licensed Septic Installer: �j��� 12 (Today's Date)
(Name----Print —Signed)