HomeMy WebLinkAboutHealth Permit # 10/18/2017 (2) N
Application for Septic Disposal System 6 - 126 0
Construction Permit — TOWN OF TODAY'S DATE
$350.00-Full Repair
NORTH ANDOVER,
MA 01845 $175.00-Component
Important: Application is hereby made fora permit to:
When filling out ZrConstruct a new on-site sewage disposal system*
forms on the
computer,use ❑ Repair or replace an existing on-site sewage disposal system* t„ t
only the tab key °~
to move your ❑ Repair or replace an existing system component—What?
cursor-do not 100
use the return A. Facility Information 15EP
v
Address or Lot#
01841
Cityfrown .51
2.-*TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump [ rauity(choose one)
***If pump system, attach copy of electrical permit to application***
❑Conventional System (pipe and stone system)
Y ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) 1
❑ 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)
Wbatis,the Make? Wiat is die Model,
2. Owner Information
_..._.......... .............._...._ _c,...... .m _
Name / �f
Address(if di ferent rorn above)
City/Town State Zip Code
4e P
Email address Telephone Number
3. Installer Information
ame Nem_�e Company
Address
1 own State Zip Code 1
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Nam !/ ...__. Name of Company
Address
c—
city/ own Sate Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
."M Application for Septic Disposal System
Construction Permit - TOWN OF TODAY'S DATE
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
PAGE 2 OF 2
A. Facility Information continued....
6. Type of Building: EI/Residential Dwelling or E]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
North Andover. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approved.
Name Date
l fic a�i 7"j, �e (Boa of H
ication Appr ealth Representative)
V
Date
Application Disapproved for the following reasons:
For Office Use Only:
1. FeeAttached? Yes
Na_
2. Project Martager Ohligation Form Attached? Yes No._-_--------
3. Pump&,,,; P Ifso, Yes No-L,1
Applicant received copy of
"Electrical Inspection Notes for Septic Systems"
Mandozit?
4. Reviewed approval letter, allpaperworkseceived? Ye.5Z No
Missing,
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
6. Floorl-)VansP(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:
Liz
(Address of septic systerh) For plans by
o (Enoieer)
Relative to the application And dated
(installer's n-anRECOVED
(Uriginal date)
Dated 90/ -7
(Today's date) With revisions dated
TOWN OP NORTH ANDOVER
(Last revised date)
HEALTH DEPARTMENT
11 understand the following obligations for management of this project:
1. As the installer,I ani obligated to obtain all permits arid Board of Ilealth approved plans prior to
performing any work on a site. Itrust have the approved plans and the pc,riwton 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
itern ffirce shall be applicable.
3. As theinstaller, I urn required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an insy
with Title 5 and the Board of Health R.Wjlat gns mayresult;in a$50.00 fine being levied a gai st me and/or
MY W"i 4_1_1y_
a. Bottom of Bed-- Generally, fl-lis is the first (Vinspection 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 OK (or e-mail to: healtlideptCci,)notdiandoveriia,,i,gov) from the engineer must be
submitted to the Board of ficalth, after which installer calls for an inspection titne. 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, 1.understand that only I may perform the work (otber than sii*le excavation)and I am:required
to complete the installation of the systein.identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can.constitute
reasons for denial of the U-i—tem-Aradtor revocation or suspension of 1WIllicense to o crate in the Town of
North Andover, sippificant fines to all.persons involved are also possible.
5. -As the installer, I-understand that I inust be on-site during the performance of the following construction
steps:
a. Dete-nnitiation that thepi-opet-elevation of the excavation Inas been zeached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Boatd ofl-lealth staff'or considtant.
d, Installation of tank,D-Box,.pipes, stone, vent,pump chamber retaining wall and other
Components.
6. As the installer,Lunde rstand that I am solely responsible for the installation of the system as per the
a.. toved plazas. No instructions by the homeowner general.contractor. oLann�QthgjLpe:rsotis.-y abs lve
shall o
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date) -'
(Name c- r i n t) (Name-sincd)