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HomeMy WebLinkAboutHealth Permit # 11/20/2017 I I Map-Block-Lot Commonwealth of Massachusetts 106.C©028 BOARD OF HEALTH -- � Pef1771C ISO North Andover BHP-21017-1092 P.1. -- _.. ....- - ---. - Ft;F' F.1. $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT { Permission is hereby granted James Boraczek _ _ to(Gonstr�xct)��n Individual sewage Disposal System. at No 10 WOODCIIUCK LAN - -----... ------ . . - �w as shown on the application for Disposal Works C,onsti•uction Permit No. BHP 017 109 > at�d Nby nber 08,2017 1 1 Issued On:Nov-08-2017 BC)AI2D OF HEALTH I l i i Application for7eptic Disposal bystem Construction Permit — TOWN OF TO DAY'S DATE $350.00-Full Repair qW NORTH ANDOVER. MA 01845 $175.00-Component Important: Application is hereby made for a permit to: When filling Out E] Construct a new on-site sewage disposal system* forms on the computer,use El Repair or replace an existing on-site sewage disposal system* only the tab key XRepair or replace an existing system component-What? to move Your cursor-do not use the return A. Facility Information key. /0 4A, Address Or Lot# *-,4ADuVV, City/Town 2.-*TYPE OF SEPTIC SYSTEM*: � [:1 Pump ,,Gravity(choose one) ***lf pump system, attach copy of electrical permit to application*** > Kconventional System (pipe and stone system) > ❑ Infiltrator or Blodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.) > ❑ Pressure Distribution S.A.S.(No D-Box) ->- Pressure Dosed-(DrBox Present)& > 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) w1ja t is th e Malre? Wbat is die Model? 2. Owner Information Na—me Adclress_(_ff different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information Name Name of Company Address ) _ / z - eCityi7own 7 438 4/f §iate ,p Cod ---------------------------- Telephone Number(Cell Phone#ifpossible please) 4. Designer Information ......... 14am"e­. Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 Application for Septic Disposal System Construction Permit - TOWN OF $350.00-Component NORTH ANDOVER, NU 01845 -Component $175.00 PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building:AResidential Dwelling or nCornmercial 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. Iia Date Appji6""jon Appirdv`e�/ y: oard of Health Representative Date APOCatiloa,6isap proved for the following reasons: For Office Use Only: 1. EeeAttacbecl? Yes No 2. Project Matzager 01YAgation T;gtm Attached? yes No,----,-- .3. Pump System? If so,Attach copy ofElectrical Perfzzit yes No AppAca-tit"ceived copy of "ElectdcalInspection Notes Joy-Septic Systems" Yes No Mandout? 4. Revieivedqpprovallette_t, allpaperwork-received? Yes No Miss-1,09.1--_ .5. Foundation As-Built?(new construction only): Yes (Same scale as approvedplaq) 6. Floor Plans?(now construction only): 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: /a Wood c4v�4 4& (Address orf septic syste,rn) For plans by Relative to the application of �AIMGJ (l'nstailer's nanie) And dated rtr,tna date) Dated �� ��/� of ay s mate) With revisions dated (East revisec]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 must have the approyed_plans and the hermit on site when any workis beim 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. Immmunderstand that requesting an inspection,without:completion oftthe_iterns in accordance with'Title 5 and the Board of Health Re u� latiQns may result.in a 5-O..(l() fine beirw levied against me and/or my ccyrrlpat���. 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 Insvection—Engineer must, first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: from the engineer must be submitted to the Board of Ilealth,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 (other than,rzrreple excavalioa) and.I am required to complete the installation of the system identified in the attached application for installation.. I further understand that work clone ley others unlicensed to install septic systems in NprdjAndover can constitute reasons for denial of the system and/or revocation ot. suspension of my license_to,operate in the Town of North Andover.,_significant fines to all persons 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 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-Boat,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer,I understand that I am solely_respo_nsible for the installation of the system as per the at�t�ro cd glans. No instructions by the homeowner,g-cneral.contractor, or any other aI_cr sotis-shall absolve me of this obligation. Undersigned Licensed Septic Installer: �i�� � (,today's Date) acne-- rin- are—Signed)