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Home My WebLink AboutHealth Permit # 10/5/2017 Commonwealth of Massachusetts Map-Bloek-tot 107.00096 BOARD OF HEALTH Y„� ,� Permit No... . ... North Andove, ° BHP-2017-0533 P.I. FEE F.1. $350.00 J DISPOSAL WORKS CONSTRUCTION PERMIT � James Kellett Pernrtsstontshereby granted J-------- -------- ----- 1, to(Construct)an Individual Sewage Disposal System. at No 127 TUCKER FARM ROAD ......-..--.---....---. -----.---_ ---._-----.--................... as shown on the application for Disposal Works Construction Permit No. BIIP-201 Date Au t A 2017 -- ------------------------------------------ Issued - -..._. ---- ----------------- Issued On: Aug-21-2017 BOARD OF HEALTH • t,:; Commonwealth of Massachusetts Map-Block-Lot 107.00096 BOARD OF HEALTH - North Andover CERTIFICATE OF COMPL,IANCI THIS 1,S TO C'ERTITY,That the Individual Sewage Disposal. System (Construct) � by James Kellett Installer at No 127TUCKER R FARM ROAD ----------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal.Works Construction Permit No. BHI-2-0-1-7-053-_ Dated August21,2017 E ---------------------------------------- Printed - -------- ----- ------ ------Printed On: Aug-21-2017 BOARD OF HEALTH t , Commonwealth of Massachusetts Map-Block-Lot 10 00096 %i BOARD OF HEALTH Permit No North Andover BHP-2017-0533 $350.00 DISPOSAL. WORKS CONSTRUCTION PERMIT Permission is hereby granted _Tames Kellett. to(Construct)an Individual Sewage Disposal System. at No 127 TUCKER FARM ROAD --- ------ --------- _.. . . ....... . __ _ _ - - --------- as ------as shown on the application for Disposal Works Construction Permit No. BIIP-201.7-053 Dated August 21,2017 ----------------------------- Issued On: Aug-21-2017 BOARD OF HEALTH Application for Septic Disposal System 6 11, Construction Permit — TOWN OF TODAY'S ATE ' NORTH $350.00-Full Repair t ANDOVER, MA 01845 $175.00-Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use Repair or replace an existing on-site sewage disposal system* only the tab key to move your ElRepair or replace an existing system component-What? cursor-do not use the return Q. Facility Information key. 7 .... l/ (G rZ .�a r-V- __ _ Address or Lot IV ................. iO! - 41 VQ WekL CitylTown _- _.__ w 2.-*TYPE OF SEPTIC SYSTEM*: Y ❑ Pump XGravity(choose one) V ***!f purrIp system, attach copy of electrical permit to application*** onventional System (pipe and stone system) Y ❑ 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) YPressure Dosed(D-Bax 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) What is the Make? What is the Model?--- 2. 2. Owner Information rz t °10 C cift t 1-6 C-0 __.._ _._.... ......._.. ... .... Npame _ ? A�drdress(if different from above) _ City/Town State Zip Code _a.._---------------, 5,7a— 7 `)3"-- /�5-&'� "_-- Email address Telephone Number 3. Installer Information y CL f - lC� ( C t - ......_..__ Yc e7c',L/A`t'..►_ ' 6- ( C CC Naive Name of Company Address lr�Y 0Statr e___...... 5 Zip� d Code Telephone Number(Cel!Phone#if possible please) _. 4. Designer Information A_i_..(..1.-, .. _. .!_� c....' • t� Name Name of Company _ _----- ....... Address City/Town State Zip Code Telephone Number(Best#to Reach) / Application for Disposal System Construction Permit•Page 1 of 2 ,rrr Application for Septic Disposal System Construction Permit — TOWN F TODAY'S ATE NORTH A�l\T]C ANDOVER, MA 01845 $350.00 5.00 -1=uli Repair $1775A0-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or (-]Commercial 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 Orth Andover. I understand that until a final Certificate of Compliance has been issued by Board of Hea h, the in '" system is not approved. ami Date gcatian Approv y Board f Health-RepresentaYtie )tNarne _.9 ..:._ �� '". w„�w�, Date � Application Disapproved for the following reasons: For Office Use Only. 1. Fee Attached? Yes No 2. Project Manager Ohligation Form Attached? Yes No 3. Pump Ssy tem? Ifso,Attach co ofEle ctrical Permit Yes No V Applicant received copy of "Electrical Inspection Notes for Septic Systems” Yes No Handout? 4. Reviewed approvalletter, all paperwork received? Yes_ No Missing'___. 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) G. Floor Plans?(new construction only): Yeses 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 systein) For plans by Relative to the application of „/,4 h) t3- X 6�_( e_-1-- " (Installer's name) And dated (, 5-, e'?�) 1 -7 Dated (211 lA_1� (1) (.w0 (1 higt)"d(late) (I oday'S(late) With revisions dated - 'A (Last revises, clate) 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 prLor to performing any work on a site. I must have the al--)-Vrovcd plans and the permit on site 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 reauesting an inSDection.without completion of the items in accordance with'ritle 5 and the Board of Health Regulations may result in a S50.60 fine being levied against me and/or my comliatV. a. Bottom of Bed—Generally, this is the first (I') 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 Ins-oection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK(or e-mail to: healthd LIt Lq�tL) I Ge _�LLigftlorthandover.com) 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 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 (ollgertbansimple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed toinstall set)tics ystems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, si�)_nificant fines to all persons involved are also possib le. 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 reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other components. 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, general contractor,orany-other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (l'odays f)at(,,) 4e (N (Ne am -..-Print) 25�/Signed)