HomeMy WebLinkAboutPermits - 537 BOXFORD STREET 5/30/2018 6�i��1fV�� ��,•. Commonwealth of Massachusetts Map-Block-r..ot
���/%�' BOARD OF HEALTH 105,co025
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Pemtit No
North Andover BNP-2018-0144
FEE
$175.00
DISPOSAL., WORKS CONSTRUCTION PERM
Permission is hereby granted John L. DiVince�:nzo d. °aa
a
to(Repair)an Individual Sewage Disposal System,
at No 537 BOXFORD STREET
-- --
as shown on the application for Disposal Works Construction Permit No, BfIP-2018-014 ated M l'
,. .
Issued On: May-18-- -- QA OF HEALTH
............................................................................................................................................................................
i
53713OXFORD STREET
Reference Jo: 3 1, -20.1 - t1 1
Permit No: IIP-203 -0144
Department: ...................................
North .Andover BOARD OF HEALTH
........................................................................................ Account Ho; 1001001.1.5.0510.00
Fee Type:
.................................. ;
C- ,ynn on n Repair PE3 1T f eceipt o R C-2(118 000
� y
648
'aid Bard in f=ull On: Friy 1115.......
John 1,. iVin n o ..... ...... ..................
Received E Check No: 171.1 .......,..
Toni Woffenden
DEPARTMENT'S COPY Arnount;
$175.00
..
,.. ..............................�
i
Application for Septic Disposal System
TODAY'S DATE
Construction Permit - T OWN OF
$350.00-Component NORTH ANDOVER, MA 01845 $175.00-Component
Important: Application—ishereby made for a permit to:
When filling out F-1 Construct a new on-site sewage disposal system*
forms on the
computer,use E] Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your U�epair or replace an existing system component-What? t
cursor-do not
use the return A. Facility Information
key.
Address or Lot#
City/Town
2.-*TYPE OF SEPT!E, SYSTEM*:
> D Pump N,19-ravity(choose one)
***If pump syyem, attach copy of electrical pert-nit to application"*
> Kj,'Conventional System (pipe and stone system)
> D Infiltrator or Biodiff user(Gravel-Less) (Attach a copy of your certification to install this type of system.)
> Q Pressure Distribution S.A.S.(No D-Box)
> El-Pressure Dosed(Da. ox Present)S.A.,S-.--- -
> E] Does the system require an effluent filter? Yes— No r
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 die What is the
2. Owner Information
Name
Address(if different fro_T above)
V
City/Town State Zip Code
_ffm_afladdresss Telephone Number
3. Installer Information
t Vj iv e_e
eazt, i,T- c eov
Name Name of Company
—,5j-
et
�AMe Y3 61
dd2"/ '
City/Town State Zip Code
Telephone N�irn—her-(Cell Phone#if possible please)
4. Designer Information
Name A
Name of Company
Address
State Zip Code
-Telephone-Number est#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
Application for Septic Disposal System TODAY'S DATE-'----
Construction Permit — TOWN OF
NORTH ANDOVER $350.00-Full Repair
MA 01845 $175.00-Component
PAGE 2 OF 2
A. Facility Information continued....
5. TVpe of Building: M/Residential Dwelling or RCornmercial
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
oo
Z E me al erell as the Local Subsurface Disposal Regulations for the Town of
or.
nd .F .� rstand that until a final Certificate of Compliance has been issued by
'i Bard of t e installed system is not approved.
-bate
Appi a r 4d By: (Board of Health Representative(
ate
Ap licatio/ Disapproved for the following reasons:
For Office Use
1. FeeAttached? Yes Na.__
2. Project Mamager Ohligadon Form Attached? Yes No
3- Ifso,Attach co y of El�ectdcalPeimit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes_ No-----
Handout?
4. Reviewed appxovallettei; all paper work received? Yes No
Missing..-
5. Foundation]As-Bunt?(new construction only): Yes No
(Sarre scale as appfovedplan)
6. Eloorl-Yaas?(now construction only): Yes NoK
Application for Disposal System Construction Permit-Fuge 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:
X&
(Address of septic system) For plans by
(Engineer)
Relative to the application of eeAcw
(Installer's name) And dated
(Orignial date)
Dated
1�e- 1
z (today's date) With revisions dated
(Last revised date)
I miderstand the following obligations for manageinent of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans p1do:r to
performing any work on a site. I must have the apipj.jff�e(�Ilqns�and the�rerrt�iit an site when any work is
being 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 cotripany schedules an inspection and the system is riot 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 requesting an inspection. without completion of the items in accordance
with Title 5 and the Board of.Heald-i Regulataoxas may result in a $50.00 fine beinglevied against mcandLgr
my com zany,
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 beat does not have to be present.
b. Final Construction Inspection--Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to: healthdept(p7northa.fidoveri-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 must be ready and able to cause
pump to work and alarm to function.
c. Final'_Grade--Inq
Installer must reel inspection when all grading is complete. Installer does not
have to be on-site.
4. As theinstaller, I understand that only I may perform the work (other thorn siy)y
ple 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._by others unlicensed to iristall_se tic systems in North Andover can constitute
reasons for denial of the smein and/or revocation or suspension of my license to operate in the`T=own of
North Andover, significant fines to all per sc�x�s
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
components.
6. As the installer, I understand that I am solely to,ponsible for the installation of the system aLper�the
approved plans. No instructions by the horneowner,get or any other j2�c.rsons.,shall absolve
jeral contractoi,
me of this oLligation.
Undersigned Licensed Septic Installer: da ate)
'Ao/10 6)
(Nafne—Print) 11 c— rgnec)