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HomeMy WebLinkAboutMiscellaneous - 19 BEAVER BROOK ROAD 4/30/2018 (16) Application for Septic Disposal System '7 Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $250.00—Full Repair $125.00-Component AAwlication is hereby made for a permit to: ❑Construct a new on-site sewage disposal system* ❑Repair or replace an existing on-site sewage disposalsystem* [�epair or.replace an existing system component–What? A. Facility Information l 9' 39.4 Vtrz & ta�,/� Address or Lot# v • �� /"a, O� City/Town ©I 8 Y ®Fx100 PPS MENS 2.-*TYPE OF SEPTIC SYSTEM: '�®���'�H ➢ ❑ Pump ravity(choose one) ***If pump system,attach copy of electrical permit to application— ➢ Btonventional 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 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 fflter before DWC issuance) Wintis the Makre? What is the ModcP 2. Owner Information Mame b Q,eAvete- Address(if different from above) Cityrrown State Zip Code 7 Telephone Number 3. Installer Information ow Sdi►J BATES0N ERiTrnFa _gr-R ibm Name Name of CompanA 11-ARGILLA ROAD. ANDOVER, MA 91 a10 Address Cityfrown State Zip Code 97 LV I 'D (Somcaz� 6 Telephone Number(Cell Phone#If possible please) 4. Designer Information Name Name of Company Address Cityfrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2