HomeMy WebLinkAboutHealth Permit # 3/21/2018 i
i
Commonwealth of Massachusetts Map-Block-rot
107 80050
BOARD OF HEALTH �_ - -------- ---- ..
Permit No
4
North Andover BHP-2018-0029
P.1. ............ ...
_ _ — FEE
F.I.
— — . ... _ $350.00
DISPOSAL, WORKS CONSTRUCTION PERMIT
Permission is Hereby granted Tadd Bateson
to(Construct)an Individual Sewage Disposal System.
at No 1 GRAY STREET
as shown on the application for Disposal Works Construction Permit No BHP 2018
--.._._- - _. ------
IssuedOn: Mar-21-20I8 BOARD OF HEALTH
i
l
i
Application fiatoffic Disposal System
Construction- Permit — TOWN O TODAY'S DATE
*��
$250:00'—Full Repair
NORTH A 'DO R= MA 01845 $'125.00--Component
Application is hereby made for a permit to:
Construct a new on-site sewage disposal system*
Repair,or replace an existing on-site sewage disposal'system*
E Repair or replace an existing system component—What? ;
WOP
L
A. Facility Information W
Address or Lot# I I I I
111Q jr
is �
City/Town
2.-'TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump ravity(choose one)
***Itpump system, attach copy of electrical permit to application***
A onventional System (pipe and stone system)
➢ ❑ Infiltrator or Blodiffuser(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.
A E 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 DWC issuance)
What is the Maker' Whatis thcModclt'
2. Owner Information
Mame
Address(if different from above)),,
City/Town State Zip Code
Telephone Number
3. Installer Information
Name NameofCompan Fr", W401
fi/ /fir / e i t �or�w ai..i_A i a�wr
Address q,
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Desinner"Information
Name Name f Company
Address _
/4/116(A Ady,-
Citylrown State Zip Code
(Best#to Reach
Telephone Number )
Application for Disposal System Construction Permit-Page 1 of 2
A vlrcatlan.,far- .Se tic DIs Qsaltern _ 1 .
TODAY'S DATE
z
Co11st a .0 t14 1 Permit !00
ki..LF" .�,f� (( op
$:2so.ao*-Pull ;Ir
(�1�45
iG Ufa° , .. $125 OO...Compbnent
H
PAGe 2,0.F 2
A. Facllity,Lnfor atio
m n continued,..
S. T e'of Suildin esidentlal:Dwelllng. or ElOommercial
S. Agreement
The undersigned agrees to ensure:the constructlon and maintenance of the afore=derctibed
on-site sewage disposal system,ln acc'or`dance with tie.pravlslons of Title 5 ofthe
Envlr'onmei�tal Code,as.well as the Local Sabsu`rface Disposal Regufatlons for the Town of
North Andover, and trot to placel a system 16 operation untl!a Certificate of Compliahce:has
been Issued�Y)thlsr Boatd ofHealth.
-p-
Name
p-Name Cate
Applicatppro : (Boa dofHealth Representative)
NameCrate
,.-
Applicat on DI 'approved for the following reasons:" '
For Office Use OMv
L "FeeAttached?
Yes No
2.• ProlectAliwager ObAgadon Fo=Attached? Yes., Nq.
3.: Purny Svstcrn? Ifsoi hCo. By—mit'..:
r co„pyg2 - e IVa
4. Fauadat*As-Built?(new constructtlori•ronly):
(Same scale as approvedplan)
5. FloorPlaos?'(he.w dottstructloti'only): o
AppIC tldn�or.Df$ppSat 3yster}t' onstroctlrsri Parmh Pirm 2 of 2
!
SEMC'S"S TRM.IN- AtUk-M C'AZO -qMN O, LIGATIQM
'
.An 01a•NpttlsAndavarJia=c-d&iaa4pz f 4MO d iatrgidQft'fO lhaveptia Ustewforths p=pcey4q:
a
r f �
(dd4ii u ottVc if 1Dmm) -•FC=PUM IT tc l f V4 N
(Uwbluafq,1=4 agd datrd. 1
tUgging a .
o :Onto W&rVidona datad
(L"t ravfsed date)
I understand the fbHo l#g irfiligatt3au for magcmcnt of fbb progcca
i. 14a them Ia.obiigat to obtnpcm.nd ofr �ppraPcd ps m
• �piag�p.�acislc cu3.�edtG
, ta]Ir.�;rl, i i II a and iA*q xdam horpca a aaat xct Fes*- $ r ar unp
ao.pr,mcn Ltot"goc&taed with my't pkT g&gduks•m laspron and the vptcta is ndt=dp,&k ft
' t t�.h ue y wo #et�d pitoaE10 thc.appi bis wpictiogs sus
.' ` Y• • y
! . e
• ad b�don �• � ��n# pd� �t�cs•r�at}�uvc t�bti p�ap�•.
b. _ t ciar'tltdpc�st f Ctcvrona; etr.
. � '• s c �L OI�'�az Ntx�•irx Ftnns.the aa�must
3?a#ubLuitted#tlxc.
bDVtxd"Of fit. � ytn ec4m. G'I at Iri41�t
6aptitar fdt ,� +
let.puft �Y'ovetic.,tst std sb#c to
t �^ at C�It3t 3'r 1i ?'Iti6 Cti4b�7�1 1 t�{tt rAitl j tC; Wu does got
hive to bG zate.
4. l s he installer'I end rhAtaitip FOAM Pi a t'�clbrr't r�,,(a. ac atr�q�d jmt red
-in compleft the is of the
S
rk
U6 ham mgmill4lif
Yn '
�,. .�rh thC.�.ttEt�et,l�ui�tsststad • �t[�E '�C•t7����2�• �CC't1�t73� •'
'atepta,• '•+ • , •p �cg rctt�st�c€iirm• .
+t: Det�xnlt�ati�a��hal.�Ft��p�rtkv�t�aauft�rtr�auarl�s�'X��-c�rteacfic�3t- • '
Iiaa oftre'ardxadtiaeto
C. ' r rl rapeo0=bpRom deOrA*tb0*a tr6wua w.
d rote wa 60 it Gro k J2-.Wa.V jpg4 tit, v�aat,� *iot �ci; e�tx xr��l�urlla�h�r
ORTN
Town of North Andover
HEALTH DEPARTMENT
CH
CHECK#: 1833 DATE: 3
. .........
LOCATim:
H/O NAME:
CONTRAcrOR NAME:
Typeof Permit cmr ljense. (Check box)
0 Animal
0 Body Art Establishment
0 Body Art Practitioner
0 Dumpster
0 Food Service-Type:--
0 Funeral Directors
0 Massage Establishment
0 Massage,Practice
0 Offal(Septic)Hauler $
0 Recreational Camp $
0 Sun tanning
0 Switnining Pool
0 Tobacco $
0 Trash/Solid Waste Hauler $-
0 Well Construction $
SEPTICS tnys.-
0 Septic-Soil Testing
0 Septic-Design Approval $
Septic Disposal Works Construction(DWO $
0 Septic Disposal Works Installers(DWI)
0 Title 5 Inspector
0 Title 5 Report
1:1 Other. (Indicate)
Heath,,Agent Initials
White Applicant Yellow-Health Pink-Treasurer