HomeMy WebLinkAboutHealth Permit # 1/8/2018 i
—._ — — Map-Block-Lot
Commonwealth of Massachusetts 107 A0080
/% 0!� % •• BOARD OF HEALTH Hermit No
BHC'-2015-0233
North Andover -- .
FEL:
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Robert Daigle __ --Permission is hereby granted ..__.__ __ ___________ ______ __ __ _ _
to(Upgrade)an Individual Sewage Disposal System.
at No 410 SUMMER S_ 'tR-,_E w --_-. - _ 8,201s
as shown on the application for Disposal'Works Construction Permit No. 13HP 2 023I7ated May 2
l� w,,...
Issued On May-28-2015 BOARD OF HEALTH
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N. Application for Septic Disposal System l ix
Construction Permit — TOWN OF TODAY'S ATE
NORTH ANDOVER MA 01845 $125.00 -Component
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system* J
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. IWO
Address or Lot#
...........__...n..-__ ._. .._ ---.. — -- ----
iiy/Town
MAY 2 8
2.- *TYPE OF SEPT SYSTEM*:
❑ Pump [!],'Gravity(choose one) TOWN OF NORM ANDOVER
***!f pump system, attach copy of electrical permit to application*** HEALTH DEPARTMENT
> Q Conventional System (pipe and stone system)
Y ® 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 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)
Whatis theMtke? What is the Model?
2. Owner Information
Name
Address(if different from above)
City/Town State Zip Code
__...__------._------__
Email address Telephone Number
3. Installer Informatio
Name me of Company
Address
a, r%f�l
City/Town State Zip Code
T phone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address -
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit Page 1 of 2
,��,�Irru�,•. Application for Septic Disposal System �..
Construction Permit - TOWN OF TODAY'S DA E
$ 250.00 Full Reir
NORTH ANDOVER, MA. 01845 $125.00 -Component
PAGE 2 OF 2
A. Facility Information continued...
5. Type of Buildinw/ Residential Dwelling or ❑Commercial f
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 117'stalled system is not approved.
N me Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
L Fee Attacbeda Yes Na
2. Project Manager Obligation Form Attached? Yes No
3. Pump 3vstern? If so,Attach copy of Electrical Permit Yes No
Applicant received copy of
"Eleco cal Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed approvalletter, all paperwork received? Yes........... No
Missing
5. Foundation 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:
(Address of scpic systern) For plans by rn�
Relative to the application of
And dated P,
I (Original date)
Dated 211
(I oday's date) With revisions dated 0118St �TA?k'ed (hft)
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 pLior to
performing any work on a site. I must have the,aDmoved i31ans and the permit on site when any work is
being done.
2. As the installer, I inust,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. I understand that reauestin)-an inspection, without completion of the items in accordance
with Title 5 and the Board of Health Regulations ma v result in a$50.00 fine beinL),levied against me and/or
my company,
a. Bottom of Bed— Generally, this is the first (1'7 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, tics, etc
As-bat of verbal OK (or e-mail to: healffidelL.0 t
�,�,to�v�iofiioj,-tli�iticlo�,,cr.coLiLi) from the engineer mus
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 11)an sivzple 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 bv 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 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-Box,.pipes, stone, vent,pump chamber, retaining wall and other
m
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the li.o.meowner. general contractoror any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: ffo&ay's Date)
fw
_7Nanic Signed)
(Name :'rant I