HomeMy WebLinkAboutHealth Permit # 10/30/2017 Commonwealth of Massachusetts Map-Block-Lot
104.!70051
° BOARD OF HEALTH
Perr„it No
North Andover BHP-2017-0549
P.1.
—_ ._...,._ FF,L
F.1.
$350.00
DISPOSAL WORKS CONSTRUCTIM4 .PERM]T
Permission is herehy granted Bateson int
to(Construct)an Individual Sewage Disposal System.
at No 42 FOSTER STREET
as shown on the application for Disposal Works construction Permit No. BI1P-20 7-05 ated S r 1 017
Issued On: Sep 1.2-2017 tOA
�10F HF,ALTH
4 Application for .g tic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
NORTH�-r nr c� C $250!00'—Full Repair
NO TH ��OOVER,R,, M 01845 $1,25.00k-Component
Application is hereby made for a permit to:
E]Construct a new on-site sewage disposal system*
[Repair or replace an existing on-site sewage disposal'system*
Q Repair or,replace an existing system component—What?
A. Facility Information '
Address or Lot#
Cityfrown
2.-*TYPE OF SEPTIC SYSTEM*:
➢ ump []Gravity(choose one)
"T pump system, attach copy of electrical permit to application***
➢ Q Conventional System (pipe and stone system)
➢ ❑infiltrator or Biod€ffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
A ❑Pressure Distribution S.A.S.(No D-Box)
➢ ❑ Pressure Dosed(D-Bax Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES=(no further info.needed)
NO=(installer must specify brand of Offer before DWC Issuance)
What is theMakcP A 1��_�- Whatr'stheModlk�
2. Owner Information /
Name
Address(if different from above)
/07
City/Town State Zip Code
Telephone Number
3. Installer Information j
Name Name of Co an_y
/l ( 7.' ,,OP,11:=N1"C=:rirl lSf"S ING
AddressA Fi
AIVf�(JVt , MA G1Si-1
0
Cityrrown- - State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer-Informration
Name7 ame of Compan
,,,,;
Address
kW
Cityfrown State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
I
i
A 1icaLlo.-h for.Se tics oral System �.
(7DA1^S pAT
14 ND OA 01$ 5 $:2so.00,»Ful!Repair
$12S'M:-Pphiponent
PAGE 2 C.lF 2
.
A. Fa Ility. InLo at
Ion continued....
....
S. Typwof 13uliding:.O-Residentlgl..Dwdlllhg or 00ommercfal
13.,A
greement
The undersigned agrees to ensure the construct/on and maintenance of the afore-described
on-site sewage dlspasal systemin accordance with rite pravlslons of Title 5 of the
Environmental Codex as.well as the 4001 Subsurface Disposal Regulations for the Town of
North Andover, and not to place.1he system 1n operation until
.e Certificate of Compliance has
been Issued by this Board of Health.
Name nate
Application Approved By: (Board of Health Representative)
Name Crate
Application Disapproved for the following reasons,"' `
For Offiae Use Only:
I Pee Atmhed? Yes '
No
2,• Ftolcct,l gb-a et Oblr' don Form Attach t„
ga ed? Yes No
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r Nb
4. Fvunda#atrAs Brultr (hew consfructlon•ronlyr): Yes NO
(some scale as apptovedp14a)
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