HomeMy WebLinkAboutHealth Permit # 11/20/2017 i
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Commonwealth of Massachusetts Map-Block-Lot
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BOARD OF HEALTH .. .
a PermitNcr
BHP-2017-1 101
North Andover
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P.I. y FEL
F.I. $350.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted James Kellett
to(Construct)an Individual.Sewage Disposal System.
at No 62 FARNUM STREET ------
------- - _ ---- . _..
as shown on the application for Disposal Works Construction Permit No BI.IP-2017-ite d ver er 1 ,�017
Issued On:Nov-16-24717 BOARD OF HEALTH
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Application for Septic Disposal System ..
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Construction Permit �- T OF TODAY'S DATE
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*
forms on the
computer,use epair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
key.
Address or Lot#
tan „
All,
Tanen *
City/Town *
2.- TYP 4F SEPTIC SYSTEM ..
Pump ❑Gravity(choose one)
***If p p system, attach copy of electrical permit to application***
Y ❑ Conventional System (pipe and stone system)
❑ 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-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 filter before DWC issuance)
What is the Make? What is the Models _
2. Owner Information m
Narjc
Address if different fr m above)
�
City/Town _.. ...__ State _..._ Zip Code
Email address Telephone Number
3. Installer Information
Name
, Name of Company
e *� ° l ,P" � 1/�_- —
- —.
Address ...._.._m^_ .w......... �
Cite �� Zip Cha^
t
y To n State ,p ode a
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Wa
N e Name of ompany
Address
---------.._----
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
1
Application for Septic Disposal System
Construction Permit - TOWN OF TODAY'S DATE
1$350.00-Full Repair
NOR'T'H DOVER, 1� 01845 $176.00-Component
PAGE 2OF2
A. Facility Information continued....
f
6. Type of Building: Residential 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
North Andover. I u ersta'd toat1intil a final Certificate of Compliance has been issued by
is oard of Heal , th staled stem is not approved.
Nam Date
@g �d
N
Applic. i Ap�0 is (Board of Health Representative)
Name Date
App(cation Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
.2. Ptoject Manager Obligation Foam Attached.? Yes i- No
3. Pum S stens? If so,Attach copy ofElecttical Permit Yes No
)(
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed approvallettet, allpaperworkreceived? Yes_ No
Missing:
5. Foundation As-Built?(new construction only): Yes No
(Swine scale as approved plan)
f. Floor Plans?(new construction only): Yes_...,_ No
Application for Disposal System Construction Permit•Page 2 of 2
4
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
aU i
(\e dress of septic.sys¢cna) For plans by � � � 4 to c'
Relative to the application of a ''"--e Il
(Installers narne,) And dated
rti>tnal ate
Dated J'
With revisions dated ,
(Lash 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 plansr�ior to
performing any work on a site. I must have the approved plans and the permit on site when any work 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 required to have the necessary work completed prior to the applicable inspections as j
indicated below. I understand that requesting an inspection,without completion of the,items in accordance
with Title 5 and the Board of Health Rei;ulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally, this is the first (1") inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, tries, etc.
As-built of verbal.C)I (or e-mail to: laa.alta<micptf(t�t: )A titLftiortliati(i i,er.ca)tt) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final.Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer,I understand that only I may perform the work (other than simple excavation)and I am requited
to complete the installation of the system identified in the attached application for installation. I further
understand that work clone by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer, I understand that I trust be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board of Health staff or consultant.
d. Installation of tank, D-$ox, pipes, stone, vent, pump chamber, retaining wall and other
components,
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
improved plans No instructions by the homeowner,general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: ,.'' ,�'` �� 'I'uadalrs ate) 1
(Name__I rant ( fir c Signo
