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HomeMy WebLinkAboutHealth Permit # 3/9/2018 I �II f Commonwealth of Massachusetts Map-Block-Lot t %�l/��I��//�,�����y • 107ooasa /i BOARD OF HEALTH T'ermitNo BHP-2018-0021 North Andoverc, _ P.I. FEE: F.I. $175.00 DISPOSAL. WORKS CONSTRUCTION PERMIT Permission is hereby granted jolin L D1Vineenzo to(Construct)an Individual Sewage Disposal System. at No 89 GRAY STREET � as shown on the application for Disposal Works Construction Permit No Bl-IP-2018- Dated ar 18 Issued On:N1ar-06-2018 BOARD OF HEALTH 1 i I . 8 Application for Septic Disposal System Toas DATE Construction Permit -- TOWN OF NORTH ANDOVER, MA 01845 $175.00-component Important: Application is hereby made fora permit to: When filling out ❑ Construct a new on-site sewage disposal systern* 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 Q. Facility„InforlYiltlOn �3 S_7— key. , „, Address or Lot# "' 7. City/Town 2.-*TYPE OF SEPT I C SYSTEM*: - -__— �1 � n Y ❑ Pump Gravity(choose one) ***If pumystem, attach copy of electrical permit to application*"* ➢ Conventional System (pipe and stone system) Y ❑ Infiltrator or Biodiff user(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-Box r resent)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No L°" Ifyes, does plan specify make and model of filter? YES =(no further info, needed) NO=(installer must specify brand of filter before DWC issuance) Wliatis the Make? _._ Whatis dieModel? ____---- 2. Owner Information _ ..... Nam g Addr ,s(if different from above) CityCC/Town� �— State Zip Cade Email address Telephone Number 3. Installer Information lS Name - Narne of Company eL Addie Ciiy/Town St td e� Zip Code Telephone Number(Cell Phone#If possible please) 4. Designer Information Name Name of Company i i Address CiiyffawrrState Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page I of 2 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: Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-si a ewage isposal system in accordance with the provisions of Title 5 of the Envi o me t C de, a ell as the Local Subsurface Disposal Regulations for the Town of No h nd v r.,)1 and rstand that until a final Certificate of Compliance has been issued by thi ar o 6 It the installed system is not approved. 1 N .e Date AJJ,i tion /��Vpro�ve ry.. Mrd of Wealth Representative) Date Application Disapproved the following reasons: For Office Use Only: 1. Fee.Attaclred? Yes No Z. Project Manager Obligation Form Attached? Yes No 3. Putnam stern? I1'so,Attach coy of Electricall'e-emit Yes _ No..-------. Applicantteceived copy of "Electrical Inspection Notes fot Septic Systeins" YesNo Handout? 4. Reviewed approval-letter, all paperwvo-r1c i-eceived? YesNo Missitig: _ 5. Foundation As-Built?(new construction only): Yes Nol (Satxse scale as approved plan) G. Floor•Plans?(new construction only): Yes Nv l �, Application for Disposal System Constniction 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: c-N (Address of septic syst6i For plans by (E n L)in e e r) Relative to the application of And dated (installer's name) (Mriginal date) Dated With revisions dated (I oday's date) (Last 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 plans pil-11T to performing any work on a site. I must have th, rk is being done. 2. As the installer, 1. 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 d-A-ee shall be applicable. 3. As the installer, I am required to have the necessary work coint')leted prior to the applicable inspections as indicated below. I understand that requesting an ins pecttQpwithout completion of the:items M' accordance with'I'ide 5 and the Board of Health Ke�hation_s� — -maTresultin a 50 00 finebeinglevied 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 Ins !etjQp—Engineer must first do their inspection for elevations, ties, etc. As­bLdlt of verbal OK (or c-rnail to: healthdept@,tior.thatidove:rma.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 worktnust be ready and able to cause purnp, to work and alarm to function. c. Final Grade--Installer must request inspection when all graditig is complete. Installer does not have to be on-site. 4. As the installer, ]'understand that only I may perform the work (other than simile excawfion) 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 systems in Nardi Andover can constitute reasons for denial of thee to operatein the Town of North Andover, sJgr ficant fines to all pc involved are&Qb -possi le. 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. Final inspection by Board ofHealth staff or consultant. d. Installation of tan1c, D-Box,,pipes, stone, vent,pump chamber, retaining walta-nd other components. 6. As the installer, I understaLid that the installation of the systern as per the )roved plans. No instructions b th ho towner general contractor.. or any other persons shall absolve C, me of this obligatio ons , no Under ay s 'ate) .signed Licensed Septi V -(Name Print) (Nai Signed) pO�Try Town -,(North Andover I3EALTIHC DEPARTMENT �'�sac��uset CHECK#: 0(0DATE: .. , LOCATIOP Wc,� e:k", H/O NAME: a CONTRACTOR NAME: npe of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ _ ❑ Body Art Practitioner ❑ Dumpster $ __ ❑ Food Service--Type:_, $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(,Septic)Hauler $ ❑ Recreational Camp ❑ Suit tanning $ ❑ Swimming Pool ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $_ ❑ Well Construction $ SEPTIC Sy terns: ❑ Septic-Soil Testing $ ❑ Septic-Design Approvals p, � �� $ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 deport $ ❑ Other:(Indicate)_ $ health Agent Initials White-Applicant Yellow-health Pink- Treasurer Residential Property Record Card#1 of 1 Parcel Year:2019 PARCEL ID: 210/107.D-0030-0000.0 MAP 107.1) BLOCK 0030 LOT 0000.0 PARCEL ADDRESS: 89 GRAY STREET as of.3.19/2018 PARCEL INFORMATION Use-Code: 101 Sale Price: I Book: 11247 Tax Class: T Sale Dale: 711012008 Page: 92 Tot Fin Area: 2312 Sale Type: B Cert/Doc: Tot Land Area: 1 Sale Valid: H Owner#l: GORDON, DIANA Grantor: GORDON, PETER J Owner#2: Address#1: 89 GRAY STREET Inspect Date: 812412012 Road Type: T Exempt-B/L%: 010 Address#2: Meas Date: 114/2012 Rd Condition: P Resid-B/L%: 100/100 NORTH ANDOVER MA 01845 Entrance: X Traffic: M Comm-B/L%: 0/0 Collect ID: RRC Water: Indust-B/L%: 010 Inspect Reas: R Sewer: Open Sp-B/L%: 010 RESIDENCE#1 INFORMATION LAND INFORMATION NBHD CODE: 6 NBHD CLASS: 6 ZONE: R2 Style: CL Tot Rooms: 8 Main Fn Area: 1324 Attic: Seg Type Code Method Sq-Ft Acres Influ-112/3 Value Class Story Height: 2 Bedrooms: 4 Up Fn Area: 988 Bsmt Area: 1324 Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1200 1 P 101 S 43560 1 100/ 215622 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: Masonry Trim: Ext Bath Fix: Tot Fin Area: 2312 Foundation: CN Bath Qual: T RCNLD: 333546 Kitch Qual: T Eff Yr Built: 1983 Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1975 Sound Value: Fuel Type: 0 Grade: G Cost Bldg: 333500 Fireplace: 2 Bsmt Gar Cap: 2 Condition: AG Aft Str Vall: DETACHED STRUCTURE INFORMATION Central AC: Y Bsmt Gar SF: Pot Complete: Aft Str Val2: Str Unit Msr-1 Msr-2 E-YR-Bit Grade Cond %Good P/FIEIR Cost Class Aft Gar SF: %Good PIF/E/R: /100/100/82 PG S 1200 1988 A A 150//42 27200 1 Porch Type Porch Area Porch Grade Factor SE S 160 1999 A A /50//45 1300 1 E 160 VALUATION INFORMATION SKETCH Current Total: 577600 Bldg: 362000 Land: 215600 MktLnd: 215600 16 Prior Tot: 577600 Bldg: 362000 Land: 215600 MktLnd: 215600 E 10 160 Sq,Ft. 10 PHOTO 46 8 16 14 6 441 FU FM/B j I 988 Sq.Ft1 324 Sq.Ft. 5443q.Ft 26 26 24 14 38 1 8 12 89 GRAY STREET e ffj � i North Andover Health Department (ommunity and Ronomi(Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 89 Gray Street MAP: LOT: 30 INSTALLER: John Divincenzo r DESIGNER: , PLAN DATE: i ;' . ❑ BOH APPROVAL DATE ON PLAN: D-Box Repair INSPECTIONS ❑µ. TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by l SOIL ABSORPTION SYSTEM (General) © Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- Z Deck, on footings, etc 5 10 -- ® Waterline 1.0 10 101 ® Private drinking well 75 1001 50 ) ® Irrigation well 75 100 ® Surface Water 25 50 t ® Bordering Vegetated Wetland 1 Salt Marsh, Inland/ Coastal Batik 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) .150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim.Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foun(lation 10(5) 20(10) ® Drywells 20 25 I 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA i wetland bylaws