HomeMy WebLinkAboutHealth Permit # 11/27/2017 Commonwealth of Massachusetts 10Map-Block-Lot
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BOARD SOF HPermit--
� � � � ��� rn�it No
w BHP-2017-0568
North Andover
FEE
$350.00
DISPOSAL, WORKS CONSTRUCTION PERMIT
i
Permission is hereby granted J ohtiT Shaw, 111
to(Construct)an Individual Sewage Disposal System.
at No 127 VEST WAY
as shown on the application for Disposal Works Construction Permit No. BHP-2.017-056 ated Sept b 7, 017
Issued On: Sep-27-2017 )A OF I-IEAIATI
I
Application for Septic Disposal System 9
TODAY'S DATE
Construction Permit — TOWN OF
$350.00-Full Reair
NORTH ANDOVER, MA 01845 $175.00-Componpent
Important: Application is hereby made for a permit to:
When filling out F-1 Construct a new on-site sewage disposal system*
forms on the
computer,use Q4 Repair or replace an existing on-site sewage disposal system* RECEIVED
only the tab key
❑to Move Your F1 Repair or replace an existing system component—What?
Q
cursor-do not SEP 2017
use the return A. Facility Information
key. ToWqOF NORTH ANDOVER
Address or Lot# EV
CIY11'1�5 SEP 2 7 7.017'
City/Town
2.-*TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER
� 0 Pump Pq Gravity(choose one) HEALTH DEPARTMENT
***If pump system, attach copy of electrical permit to application"*
> El Conventional System (pipe and stone system)
> Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
> Pressure Distribution S.A.S.(No D-Box)
> ❑ Pressure Dosed(D-Box Present)S.A.S.
> ❑ Does the system require an effluent filter? Yes K 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 Me Make? W15at is the Model?--
2. Owner Information
Name
tle.
Address(if different from above)
City/Town State Zip Code
Email -_ Telephone Number
3. Installer Information
C 0 ")a�
............... ------------ A2//o/
NameName of Company
Address
City/ omw n State Zip Code
Telephone Number(Cell_Phone#_-i—fpossible- please)
4. Designer Information
Name 4 Name of Company
el
Address
49/
_67it—yrrown" State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
w� niq� Application for Septic Disposal System
,Ni to TODAY'S DATE
Construction Permit — TOWN OF
$360.00-Full Repair
NORTH ANDOVER. MA 01845 $175.00-component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: WResidential 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 system is not approved.
Date
I ptio pprove y: ( ,o of��_!
olth..Reresentatr"ve) ry .
�wn r
ame Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attaclied? Yes _ No
2. Project Manager Obligation Foran Attached? Yes_"W No
3. Pump Systetp? If so,Attach copy of Electrical Permit Yes No "`` /
Applica.nt received copy of
"Electricallnspection Notes far Septic Systems" Yes No-._
Handout?
4. Reviewed approvalletter, all paperwatk received:? Yes No
.Missing: _
5. Foundation As-Built?(new construction only): Yes No
(SaYne scale as approved plan)
6. 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:
(address of septic system) For pians byl
(Fngineer)
Relative to thea application of
pp ....
(Installer's name) And dated
ry rIgina ate t
Dated / 6_A/
(7 oday s elate With revisions dated �t 4"/��
(Last revised date) 1
I understand the following obligations for management of this project:
1. As the installer,l am obligated to abtain all permits and Board of Health approved plans prier to
performing any work on a site. I must have the—app plans and die hermit on site when any ork is
------
beingdone.
2. As the installer, I mist call for any and all inspections. If homeowner, contractor,project:manages:, 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. I understand that rc, nesting an.. spectiosa,without completion.of_the items in accordance
with.Tide 5 and the Board of Health Reulations may result in a $50.00 fine being levied against me and/or
my m pan .
a. Bottom of Bed;— (3-enerally, this is the first (1g) inspection unless there is a retaining wall,which
should be clone first. `t'he 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-built of verbal O (or e--mail to: healthdept@northandoves-ma.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. A.s the installer, I understand that only I may perforin the work (other than sive ple 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 by others unlicensed to install septic,systems in North Andover can constitute
reasons for denial of the..gystem and/or revocation Q.t suspension of my license to ape xate in the Town of
North Andover:, significant fines to all persons involved are also possible.
5. As the installer,l: understand that I must be on-site during the performance; of the following construction
steps:
a. Determination that the ptoper elevatio.a of the excavation has beers reaclied.
h. Inspection of the sand and stone to be used,
c. -Final inspection by Board ofHealth staff ox consultant.
d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining-wall and other
cornporients.
6. As the installer�I understand that I am solely_ esponsib.le for the installatiacx of the system as per the
approved plans. No instructionsby the homeowner,general contractor, or g,11y other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: / ,lt>,�. -. (f odaDate)
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