HomeMy WebLinkAboutHealth Permit # 10/31/2017 I
Commonwealth of Massachusetts Map-Block-Lot
038.00066
BOARD OF HEALTH
Permit No
North Andover BFIP-2017-0586
P.I. FEE
F.I. ... - $350.00
-------_....
i
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted James Kellett
to(Construct)an Individual.Sewage Disposal System.
at No 535 SALEM STR1 ET'
as shown on the application for Disposal Works Construction Permit No. BHP-20I7-0 ated Obe _ _11
7
Issued On: Oct-18-2017 L3OA�ZD OE HEALTH
Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
$175
.00 Full RepairNORTH ANDOVE A 01845 00-Component
Important: Application is hereby made for a permit to:
When filling out E] Construct a now on-site sewage disposal system
forms on the
computer,use X�Repair or replace an existing on-site sewage disposal system*
only the tab key El Repair or replace an existing system component-What?
to move your
cursor-do not
use the return A. Facility Information
key. I
6-I - _i
�zl
Address or Lot#
e�elz
City/Town
2.- *TYPE OF—SEPTIC—SYSTEM*:
> El Pump Gravity(choose one)
***If pumKystenq, attaqc'copy of electrical permit to application***
> Conventional System (pipe and stone system)
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)
> n Pressure Dosed(D-Box-Preserit)S.A.S-..--
> n 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)
Wb'qtistjjeM,qkc?
w7ifitis the Model?____
2. Owner Information
Name
ty
p,r 0 C1 A<7
---------
-------------—
_AdrTcss(if diffverer..,t from above)
.itv/
,it��Town State Zip Code
-—-_-_-----
'Er—nail address Telephone Number
3. Installer Information
A*.
Name Name of Company
Address
Cit?J Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
C"
Nam6 Name of Company
Address
-6itylTown Sfate -/ Zip Code
Y,
X5 y
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
Application for Septic Disposal S
ystem
ToDAY'S DATE
Construction Permit — TOWN OF
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
PAGE 2 OF 2
A. Facility Information continued....
r>. Type of uilding:'Wesiclential Dwelling or.FICornmercial
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
I h Andover. I underst h t until a final Certificate of Compliance has been issued by
this oard of He4alth, then s tem is not approved.
hl
Al
,/PName Date
A atio Apprc� d By: (Board of Health Representativq)
e Date
Application Disapproved for the following reasons:
For Office Use Only:
1. FeeAttaclied? YesesN9
2. P-tojectMat2ag-et0l)ligatio-t2T,ofmAtt,-irhed? Yes L7, No
3. Pq
yster ? If so,Attach co(2
v of FSlectrical Pctmit Yes No
Applican t"ceived copy of
"MectticalInspection Notes 1br Septic Systems" Yes No
Handout?
4. J?evieivedappiovallettei, allpaperworkfeceivecl? Yes.----, No
Miss-l"19:_
.5. Foundation As-Built?(new construction only): No
(Same scale as approved plan)
G. Floor-Plans?(new construction only): 'Yes
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 L
(Engineer)
Relative to the application of j
(Installer's name) And dated �41 Q
d(uriginal daid)
0, With revisions dated e
( �)
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, lam obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I inusthave theapproved plans and the permit on site when a* work is
be -1 doite,
a,g--
2. As the installer, Lmust 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 thi.-ce shall be applicable.
1 As the installer, I am reqiiired to have the necessary work completed prior to the applicable inspections as
indicated below. I-understand. that rec nesting an inspection.without completion o£-the items in accordance
withl'itle 5 and the Board of Flealth Regulations may rtns�t in a$50.00 finc:_bei_n_,g levied against tae andLor
Lny i any.
a. Bottom of Bed--Generally, this is the first (1't) inspection unless there is a retaixiing wall,which
should be done first. lbe installer must request the inspection but does not have to be presexit.
b. Final Construction Inspection--Engineer incist first do their inspection for elevations, ties, etc.
As-built of verbal OK(or e-mail to: bealthdcl?t@no-ttharidoverria,,i.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 must be ready and able to cause
pump to work and alarm to function.
c. Final Grade Installermust 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 siviple 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 t1yhers unlicensed to itistallseptic syste� s in North Andover can constitute
_gt� -_ 7 -- -
reasons for denial of the system aneilor revocation or suspension of my license to operate-in tliel'own of
North Andover. significant fines to 44)&rsons 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, Determination that theproperelevation of the excavatiot.7 has bo-en feached
b. inspection of tile sandand stone to be used.
c. Final inspection by Board of Health staff or consultant.
d. Installation of tank, .D-Box,pipes, stone, vent,putrip chamber, tetaining wall and other
components.
6. As the instalier,I understandthat I ible for the installation of the system as per the
jans. No instructions by the lxomeowner, etneral contractoror any other persons shall absolve
me of this obkg�jtjon.
Undersigned Licensed Septic Installer: /4/0
(Today's Date) t� 14-
igne-C
(Name—Print) __O�the -_Si�