HomeMy WebLinkAboutHealth Permit # 11/28/2017 i
Commonwealth of Massachusetts Map s° '..°t
10s B0104
A%iBOARD OF HEALTH -
Perinit No
North Andover BHP-2017-1108
FEE
$350.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted James Kellett
to(Construct)an Individual Sewage Disposal System.
i
at No TURTLE LAND
as shown on the application for Disposal.Works Construction Permit No. BHP-2017- d Nov 2017
Issued On:Nov-28-2017 BOARD OF HFALTH J
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Application for Septic Disposal System -7, 4 0_1
Construction Permit _ TOWN O TODAY'S DATE
NORTH ANDOVER.t'1+► A 0 p $350.00-Full repair
MA AI�cJ�4� $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 Repair or replace an existing on-site sewage disposal system*
only the tab key ❑ Repair or replace an existing system component—What?
to move your
cursor-do not
use the return A. Facility Information
key. Andress or Lot# .__.-....._
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
> Pump ❑ Gravity(choose ones
***!f pump s stem, attach copy of electrical permit to application***
5� 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 b-Box)
p
Fj Pressure,Dosed (D-Box 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 DWG issuance)
What is the Make?_____.__.__ _ Whatis the.Model? ___
2. Owner Information
A r
1 ram, ad.µ
Name
,'f 1 y1 SAL:_ tai _Qm
Address(if different from above)
k1 A
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
Name Name of Company
_.
}
Address
City/-own State Zip Code
Telephone Number(Cell Phone#If possible please)
4. Designer Information
Name _ Name of Company
Address
:_...
Cit
y State Zip Code
- k1
._.__ _..._..._..._.__„__.--
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of
Application 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; esidential 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 11 a he Local Subsurface Disposal Regulations for the Town of
111–north Andover. I underst t until a final Certificate of Complia &e has been issued by
Board of Healtp, the stalle, , stem is not approved"
N e V Date
t Boa
Code,-as
11 a fie L(]
rst t until pua
NYstall,
t s rd he sl
Appli�afio �A p -; I
�_Zyd By
�p f : and of Health Representative)
-0-Y
A VI/
I "
Nam ---------
-n L01-Y Date
Z,licat!6n Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes— No
2. PiojectMai.7age-POhligationFotmAttaclied? Yes No
3. Et"p System?�s —
Lem? If so,Attach copy ofEleettical Peripit Yes No
Applicant-received copy of
"ElectdcalInspection Notes for Septic Sys tams" Yes No
. .Handout?
4. 1?eviewedapprovalletter, affpqj3etworJc.reccivcd? Yes No
MiSSill,le- ---------------
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
6. FloorPlazzs?(new construction only): Yes No
Application for Disposal System Construction Permit-Page 2 of 2