HomeMy WebLinkAboutHealth Permit # 11/20/2017 Commonwealth of Massachusetts Map-Block-Lot
061 00004
BOARD OF HEALTHPerr.
nitNo
North Andov
BHP-2047-0558
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F.J. � �,. .��•'
$350.00
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DISPOSAL
----ISP" AL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Peter F3reen
to(Construct}an Individual Sewage Disposal System.
at No 140 BR.ADFOR.I7 STREET
ET
as shown on the application for Disposal Works Construction Permit No 13HP 2,017-055
ateciSepte ber 17
Issued On: Sep-18-2017
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� Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
$350.00-Full Repair
NORTH ANDOVER., MA 01845 $175.00-Component
Important: Application is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal system* RECEIVED
forms on the
computer,use E] Repair or replace an existing on-site sewage disposal system*
only the tab keySEP18 2017
to move your ❑ Repair or replace an existing system component—What.
cursor-do riot TOWN OF NORTH ANDOVER
use the return A. Facility Information HEALTH DEPARTMENT
key.
Address or Lot#
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
Y ump ❑ Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
Y ❑Conventional System (pipe and stone system)
Y ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
Y ❑ Pressure Distribution S.A.S.(No D-Bax)
Pressure Dosed(D-Box Present)S.A.S.
S� ❑ Does the system require an effluent filter? `!es 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)
What is the Make? What is the Madel? _..-----
2. Owner Information
-�.._�
Name
Address(if different from above)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information pe
Name Name of Company
,wry ry
Address
_ d., __Ae? -- - _ _ __.._ � _._._.....
._..__.__.. - r
City/Town State Zip Code
C
Telephone Number(Celt Phone#if possr !e please)
4. Designer Information
, ._ ....Ir, °, '� ..__.._.................
Name l� Name of Company
Address
CitylTown State ip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
1 $350.00-Full Repair
NORTH ANDOVER, MA 01.845 $175.00-Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: B"Residential Dwelling or MCornmercial
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
Applicati Appr6 e By: (Board of Health Representative)
---- .......
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Pro jectMafiaget,Ohligritir)nForm Attached? Yes Na
3. Pump
- System? ffso,.Attach_copy ofElectrica.l Pe mit Yes No V
Applicant received copy of
"Eleettical Inspection Notes for Septic Systems" Yes No J, '
Handout?
4. Reviewed approval letter, affpapct,woi*received? YesI No
5. Foui.2dation As-Built?(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:
I 9-(Q-6- A <>,
Fox lansb -Cr .ICGIer,
(Address of septic system) P y
(Engineer)
Relative to the application of
(installer's na4ne) And dated
rlgina ate.
lJated � � �„ �o
( ay s<.ate With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer,I am obligated to obtain all permits and Board of Health approved plans,prior to
pexfol-ming any work on a site. I must have the approved plans and the perms at1 4it:e when any vaxk 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 nzy company scllecludes an inspection and the system is not ready, then
itenx three shall be applicable.
3. As the installer, l: am requited to have the necessary work completed prior to the applicable inspections as
indicated below. Iunderstand that requesting an inspection,without-completion of the items in accordance
with Title 5 and the:Board of Health Regulations n-zay result:in a$50.00 fine being levied a ;air Rme:at�ld/qx
my ,corripan_y,
a. Bottom of Bed--Generally, this is the first (1'j 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 I.n_spection--Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to: bealthdept@northandoven-iia,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—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the inst aller.,I understand that only I may perform the work (other~thaii sii*le 6xcavaliota�and I am required
to complete the:installation of the system identified in the attached application for installation. T further
understand that work done by othet-s unlicensed to install septic systems in 1`Tol:th Andover call.constitute
reasons for denial of the system and/or revocation or suspension of my ltc ease tc7_operate.in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the:installer, ]"understand that I must be on-site during the performance of the following construction
steps:
a. Detenninatlon that the propet elevation of the excavation Izas been r-eaclred
h, Inspection ol'the sand and stone to he used
c. Finalinspection byBowd offlealth staff or•consultant..
d. Installation of tanla, D-Box,pipes, stone, vent,pump cha.tnhet; fetarnrng mall and other•
coMponetrts,
6. As the installe rI_under tasYd that I atrr solely res�ons�lle for, rile installation of the system as er the
Approved plans. No distinctions by the homeowner, eneral contractor, or any other person_s shall absolve
me of this ablh gt.ion..
c
/J 1
Undersigned Licensed Septic Installer: 1"w - -- (Foday's Date)
(Name •Pring afiie--71gn&� --