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HomeMy WebLinkAboutHealth Permit # 9/11/2017 f r App ca ion for .e c Disposal Systen� .. Construction Peri in — TOWN OF TODAY'S DATE $25N.Otl"—Full Repair NORTH ANDOVER, MA 01845 $125.00-Component Application is hereby made for a permit to: Q Construct a new on-site sewage disposal system* Q Repair or replace an existing on-site sewage disposal'system* epair or replace an existing system component—What? � A. Facility Information ,(- e Address or Lot# -61tylTown -- 2.-*TYPE OF SEPTIC SYSTEM*: ➢ Q Pump 5245ravity(choose one) '"IT pump system,attach copy of electrical permit to application' ➢ ❑ Conventional System (pipe and stone system) Q infiltrator or Biodiffuser(Gravel-Loss)(Attach a copy of your certification to install this type of system.) ❑ Pressure Distribution S.A.S.(No D-Sox) ➢ Q Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ 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 DWC issuance) Whatis theMakc? What is the Modc.V 2. Owner Information Mame Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name "�� Name of Comph / f �!( �" T CIV Pf1ITI'F3w ill t^, INC. __... Ij MDGV� Address 14Fi, MA l�"�.�'�� Wil '/� �. CityfTown- State Zip Code n C. 11 a f-J. . r Telephone Number(Cel!Phone#1f possible please) 4. Designer 1nforrnation i Name Name of Company Address CityfTown State Zip Code _ � t Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 AP low n forstam ronaYs far E �, .�,Qns. =.uc��on 1?�•rrrtit -� '�`C3. : �` _ T /.Yi .+� ;47 <C� =—CoMponen CH — t ..PAGE201F2" A. Facility Informs#ion . anfilued,,.. - �. . 5. Type,of Bulldinq: Residentfal.D.wellfhg or MOommercial B. Agreement The underslgned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal systent:In acc©rdance with the provlslons of Tltie 5 of the Envlronmenta7 Code, as well. the Local Subsu'rf`ace Disposal Regulations for the Town of North Andover, and hot to place.the system tri operartion until a Certificate of Compila .a has been issued by this Board of Health. Name Date Application Approved By: (Board of Health Representative) „ { Name Date Application Disapproved.for the following reasons:" ' 1ee Use only: For 01 1. -Fee Attached?:; Yes ` No ---- 2- ProlectAfgl ctagcr ObV,-waon Fo=Attaclied? Yes No A: If,so, , teach c,ky' tde111 Perm�'t' 4-'.FormdatzbtrAs*B urlt?dew constructlor��rox?rfl), yere,�° No (Same scale as approvedplan) ; A FloorPlam?'(hew.doristructiorr•oniy)r es �lppltatidn'fiar pis�ppsat`"yysterSi: cirlstr4c{lriri Parmft Raaas 2 rif a i 5EMCS`SMS 'IN�' '� ,�' .-qElaNT' LiGd�3' i?�fS An flit N9rdcAad3vrzZ=sad&asmitFs foF l#C tri n�O the�ept�c�yete d .tlne•I p e FA (AdI ef�epSt s mss Am plum by A- 'L PMIW5 R=Ohed ds ftd (Last sed dote) I undmtmd the following kbIlgatlolm for mirs3agcment o(Ob pr*ctJ el i. �tbehtatnllet,I arri.ablrgatcd tp abG�Ct.stIIpe,�ita aad"Ba�rd of�e�Itlx�tppro��p�-�� . • �7Gt6dt�pg At1�.'-4P0!3C pT�.it�'r 2. •=�t� ii r �+►� N�� #s O4tI1ICtQ�. CCt?33AgAt� 4 1Ct�fifmOdt lfC!*7k�#OC St#7C ? II �4'�'�A�¢�jmd the rp�io ndt 1e dy tjA )Gem tl�ab�all.ha�p1lc�eblo. .. '• ,, ,4SM6 q, to h�v+c t cy c� 'P��tbeAppUmblei ear spa - �•• k � ••`"- f ��C .�I� �-�a,:thatc�s sr'retng't�'I,�clr 6. al,r a b drixx i: ' w�Mu*die fbspact�s��t�ciea mat have to��prescti� . • .•. . z ob OIC'(os c-m;3!#a StamZe« iaarr Inst • �ba fubrmi�tied•ts��e.l�o�rd'af� , .,� �'vrxii #iat�.•I�st�llcx t�i'u�t be pr fcr t ,faapeedcirt, ar g#�:# att'edc}tt be mo aA able to • , •• 'eaus�put�p.tt;•4�crh �.t��.. - . . -.. .' c. � � isat ller sa t ut. nag iaaanc�i,4rdjnj�enol te: Iusi lici soca�zot Ova#Q 4. a the matxllcr,'I d that y PN. �et6rr r eNwAWN) used spa ant piece t".* * t�5a cs tete f � dippT a :Soy Itiet ilatloa: 'S.. A�th�fz �I u�crataa� t,I�aa��j��G� t����.�cx•of tfi��c,Iic �car�stan, ' IMP ' J7�slaaraah�BorunlafeAlth�1 `'otcaa� : r ilnd M bmudS c.I 4=