HomeMy WebLinkAboutHealth Permit # 11/7/2017 Commonwealth of Massachusetts Map-Block-Lot
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BOARD OF HEA Permit No
f
BHP-2017-0512
North Andove
t;•Et,
F.I. $275.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted . w..--_-_------- - ..-------- ------ -_,-------------
to(Construct)an Individual Sewage Disposal System.
at No 25 Wellington Way -.. ----- .. - -- ------ . -_
as shown on the application for Disposal.Works Construction Pertnit No 13HP-2017- . Dated ply
Issued On Jul-25-2017 BOARD OF HEALTH
i
i
1,
Application for Septic Disposal System,
TODAY'S DATE
Construction Permit — TOWN OF
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
Important: ApplicatioWfs hereby made fora permit to:
When filling out Construct a new on-site sewage disposal system* RECEIVED
forms on the
computer,use ❑ Repair or replace an existing on-site sewage disposal system* OU 16 2017
only the lab key
to move your Repair or replace an existing system component-What?
cursor-do not TOWN OF NORTH ANDOVER
use the return A. Facility Information HEALTH DEPARTMENT
key. - "I- /
L!
19-5-
Address or Lot#
—------------
CitylTown
2.-*TYPE OF SEPJIC SYSTEM*:
> El Pump ErGravity(choose one)
***If pump s stem, attach copy of electrical permit to application'
>pump
System (pipe and stone system)
> F1 Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system,)
> F1 Pressure Distribution S.A.S.(No D-Box)
> F1 Pressure Dosed(D-Box Present)S.A.S.
> 0 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 DWG issuance)
What is the Make? Tylbat is the Model?--
2. Owner Information
Name
7—A/1-1q, X'/
..........
Address(if different froMab °'el
City/Town State Zip Code
3'7 06�F`3
Emall address Telephone Number
3. Installer Information
Name Name of Company
AdAre s
city/Town State Zip Code
--222,F
Telephone Number Phone#if possible please)
4. Designer Information
'A-
Name Name of Company
Address
AO-Z-IE250...............
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
sApplication for Septic Disposal System
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....
5. Type of Building: Residential 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
North Andover. 1 understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed systen ` not approved.
Name Date
A li `ation pproved y (B and o Health Representative)
me Date
" Application Disapproved for the following reasons:
For Office Use Only: `
Z Fee Attached? Yes " No _.
2. Project Manager Ohligation Form Attached? Yes No
*�x
3. Pump Ss
tern? If so,Attach copv ofElectr calPeimrt Yes No
Applicant xe ceived copy of
"Electrical Inspection Notes for Septic Systems" Yes M,)
Handout?
4. Reviewed approvalletter, all paperwork received? Yes No
Mi.S's111 ---
5. Foundation As-Bidlt?(new construction only): Yes No
(Same scale as approved plan)
G. Floor Plans?(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:
1-,j e
(Address of septic syh4m) Fox plans by
(Engineex)
Relative to the application of,
(Installer's na-1gr And dated .23 0)
Dated (unginal date) RECEIVED
/0 ze—/ 7 Wiffi.revisions dated
(I oday-s date) (Last revised'date) 1 (11 2017
I understand the following obligations for management of this project: TOVM OF NORTH ANDOVER
HEALTH DEPARTMENT
1. As the installer, I am obligated to obtain all permits and Board of llealffi approved plansp1iot to
performing any work on a site. I must have the approved plans and t!Le permit on site when any vrork 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-requited to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that request
-without cc7mpletion of the items in accordance
with Title 5 and the Board of Health.Regulations rnaytes-cdt in a$50.00 fine being levied against me and—/or.
a. Bottom of Bed–Generally, this is the first (1")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 Inspection–Engineer must first do their inspection for elevations, ties, etc.
As-buih of-verbal OK (or e-mail to: healdidept@north,,itidovej--r.na.gov) from the engineer must be
submitted to the Board of flealth, 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---Installet 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 (other than sivaple excavation)and I am requited.
to complete the installation of the system identified in the attached application for installation. I further
"ther
uriderstand that work done by others unlicensed to install.septic systems in North Andover can constitute
reasons for denial of the sysfem and/or revocation or suspension of Inv license tri operate in theTown of
.North.Ando-vct,-si.gi-iific-,iDi fines to all persorkstkvolveds_t j.-�Iabc�_p sbe.
Qs
5. As the installer, I understand that I must be on-site doting the performance of the following consttuction
steps:
a, Detexin-ination that the proper elevation of the excavation has been-teaclied
b, Inspection of the sand aDcl stone to be used.
c. _M,nal inspection by Board of Health staff or consultant.
d. Installation of tdnk, D-Box,pipes, stone, vent, putnp cbainhei, Leta ling walland other
components.
6. As the installer, I-understand that I am solelvr.est.)onsible for the installation of the system as per the
approved plans. No instructions by-the ho�tT.ieQ tsanishall absolve
rp
.me of this obligation.
T.Jndersigned Licensed Septic Installer: "('Today's Date) 14J1;11611261
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