HomeMy WebLinkAboutHealth Permit # 1/10/2018 i
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Commonwealth of MassachUsetts
Map-Block-Lot
106Ad049
BOARD OF HEALTH
Permit No
North Andover 2017-0516
P.I. "
F.I.
DISPOSAL WORKS CONSTRUCTI I"T4 ,1= ERMI'T'
Permission is hereby granted Robert.Innis -_.------------
---------------.... _... ..
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to(Construct)an.Individual Sewage Disposal.System.
at No 1099 SALEM STREET
._. ......... . .. ..--- -- ...------------_.
as shown on the application for Disposal Works Construction Permit No. BI=IP-2017-051 ated Jul 7
Issued On: Jul-31-2017 BOAR: OF HEALTH
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Anplication for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF
NORTH ANDOVER, MA 01845 $75.00-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
to move your ❑ Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
key. 5cw/
fay3
Address or Lot#
/y .!.i Et ..wD ".
CitylTown
2.-*TYPE OF SEPTIC SYSTEM*:
> ❑ Pump ®-Gravity(choose one)
***If pump s tem, attach copy of electrical permit to application***
Y 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.)
Y ❑ Pressure Distribution S.A.S.(No D-Bax)
Y ❑ Pressure Dosed(D-Bax Present)S.A.S.
5 ® Does the system require an effluent filter? Yes No C/
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)
Wbat is the Make? Wbat is the Model,?
2. Owner Information
.......... _ .. m - t ,z -- --- .......
Name
Address(ifdifferent from above)
fp d
City/Town State Zip Code
Email address Telephone Number
f
3. Installer Information pays /f
Name Name of Company
.
Address
S
y �a
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name cJ Name of Company
—
Address 1
City/Town State Zip Code
`7n 41ge 41 / 1,
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2 j
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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
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: ❑Residential Dwelling or❑Commercial
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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.
A_. ~ x
7 /Z ._.............._..__-__----------- -—......... - .....
Name _ Date
Apcatlo roved By: (Board of Health Representatkar
N din e Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Tec Attached? Yes A No____
2. Project Manager Obligation Form Attached? Yes No
3. Pumn System? If so,Attach copy ofEleetiical Permit YesNo
py of
Al Mectricallnspeco n Notes far Septic Systems" Yes No °
Handout?
4. Reviewed approvalletter, all paper-vorkreceived? Yes No
M1sSi11g:
5. Foundation As-Built?(new construction only): Yes No
(same scale as approved plan)
G. F1oorPlans?(new construction only): Yes No 1
Application for Disposal System Construction Permit•Page 2 of 2
SEPTIC SYSTEM INSTAL LER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
0 S",x T
For plans by A.ret f"o�,V)0-
(Address of septic systeni)
(J(Engineer)
Relative to the application of And dated '
(Installer's name) 0 e 7 .„ 7 I
Prignial date)
Dated 7- 07 - 7 L7
(I'oday's date) With revisions dated "`
O.'.,ast 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 plansprior to
performing;any work on a site. 1 in-List have the approved plans and the pennit onsite when any work is
beWg 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 systern is not ready, then
item three shall 1)e 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-requesting an inspection,without completion of the items in accordance
with Tide 5 and the Board of Health Regulations giaVtesilt.in a $50.00 fine being levied against ine and/o
my compai1y.
a. Bottom of Bed— Gene-tally, this is the first (V� inspection unless there is a retaining wall,which
should be done first. The insLallerniust request the inspection but does not have to be present.
b. Final Construction Instwetion----Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK(or e-mail.to: he,,iltl-idept(i�no-ttharidoveri-na.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,rriust be ready and able to cause
pump to work and alarm to ffinction.
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 inay perform the work (olber than si;vifile excaiwfion) and I am required
to complete the installation of the system identified in the attached application for installation. 1. further
understand that work done by ethers -unlicensed to install_septic systems in North.Andover can constitute
reasons for denial of the Lsystem t�eiyuand and/or revocation suspension of license to operate in the Town of
North Andover:,significant fines to all persons involved are also,possible.
5. As the installer, 1.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. Finalinspection by Board ofHealth staff or consultant.
d Installation of tank, D-Box,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 De.r the
improved plans. No instructions by the homeowner, eneral.contractor,oxany other mi-sons shall absolve
me of this, obligation.
-Undersigned Licensed Septic Installer: (Today's Date)
_77
(Name—Pririt) _77_77.
(Name Signed)