HomeMy WebLinkAboutPermits - 178 GRANVILLE LANE 6/27/2018irduiiiiilo
Commonwealth of Massachusetts
BOARD OF HEALTH
North Andover
Map -Block -Lot
106.00076
Permit No
BHP -2018-0213
FEE
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Dean Dynan
to (Construct) an Individual Sewage Disposal System.
at No 1
78 GRANVILLE LANE
as shown on the application for Disposal Works Construction Permit No. BHP -2018-02
Issued On: Jun -27-2018
$175.00
OA OF HEAL
Commonwealth of Massachusetts
BOARD OF HEALTH
North Andover
P.I.
F.I.
DISPOSAL WORKS CONSTRUCTION PERMIT
Map -Block -Lot
106.00076
Pcrmit No
BHP -2018-0213
FEE
$175.00
Permission is hereby granted Dean Dynan
to (Construct) an Individual Sewage Disposal System.
at No 178 GRANVII.,LE LANE
as shown on the application for Disposal Works Construction Permit No. BI1P-2018-02 , ated J
Issued On:
n-27-2018
BOAID OF [-IEALTtl
CHECK #:
Town of North Andover
HEALTH DEPARTMENT
DATE:
LOCATION: LI (c,
H/O NAME: HU
CONTRACTOR NAME: h\ I( )
Type of Permit or License,: (Check box)
LJ Animal
O Body Art Establishment
O Body Art Practitioner
O Dumpster
O Food Service - Type:
O Funeral Directors
O Massage Establishment
O Massage Practice
O Offal (Septic) Hauler
O Recreational Camp
O Sun tanning
O Swimming Pool
O Tobacco
O Trash/Solid Waste Hauler
O Well Construction f2.5- $
SEPTIC System:
O Septic - Soil Testing
El Septic - Design Approval
Septic Disposal Works Construction (DWC)
O Septic Disposal Works Installers (DWI)
O Title 5 Inspector
O Title 5 Report
O Other: (Indicate)
$
i! 1
Health Agentlnitials
White - Applicant Yellow - Health Pink - Treasurer
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Application for Septic Disposal System
Construction Permit — TOWN OF
NORTH ANDOVER, MA 01845
Application is hereby made for a permit to:
0 Construct a new on-site sewage disposal system*
0 Repair or replace an existing on-site sewage disposal system*_)
,)repair or replace an existing system component — What? j7
A. FaciNcrrmation
/ / 6-' //
Address or Lot #
City/Town
2.- .*TYPE OF SEPTIC SYSTEM*:
1111 Pump 1111 Gravity (choose one)
**If pump system, attach copy of electrical permit to application***
• 11 Conventional System (pipe and stone system)
Ei Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of systein.)
>, ID Pressure Distribution S.A.S. (No D -Box)
-El-Pressure-Dosed (1:1Box-Piresent)
) LJ Does the system require an effluent filter? Yes No
Ifyes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
/64)
DAY'S DALE
$350.00 - Full Repair
$175.00 - Component
2
?fL,
'TOWNOFNe.)P.".fill, 6,11rocyvE:p
EL? rMtJfl
What's the Make?
2. Owner Information
Name
Address (if different from above)
Cityr lown
Email address
3. Installer Inforogation
$
.Lkv-f.-ea
Address
ulty/Toz
4. Designer Information
Name
What is the ModeL?
Stat
Telephone Number
Name of Cornpany
Zip Code
Fo ?
Cei/c9).r.
State
Telephone umber (Cell Phone # if p ssiblo please)
-7d6 7,31 -
Name of Company
Address
City/Town
State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
pinplication for Septic Disposal System
Construction Permit—TOWN OF
NORTH ANDOVER, MA 01845
PAGE 2 OF 2
A. Facility Information continued....
TODAY'S DATE
$350.00 - Full Repair
$175.00 - Component
5. Type of Building: DResidential Dwelling or OComnnercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the
on-site sewage disposal system in accordance with the provisions of Title 5
Environmental Code, as well as the Local Subsurface Disposal Regulations
North ver. 1 understa at until a final Certificate of Compliance has
thi oar gf He he ed system is not approved.
Da
,/y
Application Approved Jity: (Board of Health Representative),„
Name
ApplicatiOn Disapproved for the following reasons:
Date
For Office Use Only:
1. Fee Attached? Yes 1,
No
afore -described
of the
for the Town of
been issued by
2. Project Manager Obligation F01711 Attached? Yes No
3. Pump System? If so, Attach copy ofElectrical Permit Yes_ No4_
Applicant received copy of
"Electrical Inspection Notes far Septic Systems" Yes NoJ
Handout?
4. Reviewed approval letter, a 1 I paperwaticreceived? Yes
Missing:
5. Foundation As-Bullt? (new construction only):
(Same scale as approved plan)
6. Float Plans? (new construction only):
Yes_
No
Nbl
Application for Disposal System Construction 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:
/ 6 (-6 ,e -N (Jij. /g_
(Address f septic system)
Relative to the application of
Dated
(Installer's nam
7o4ays-afe)
For plans by 71('
And dated
(Unginal date)
With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
t)l)teV
,94-11
I. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site: when any work is
beingslone.
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 system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed pnor 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 Health Regulations may result in a $50.00 fine being levied 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. Finatconstruction Inspection - Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdept@northandoverma.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 - 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 may perform the work (other than simple 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 install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension. of my license to operate in the Town of
North Andover, significant: fines to all persons involved are also possible.
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.
Installation of tank; D -Box, pipes, stone, vent, pump chamber, retaining wall and other
componefltS.
6. As the installer, I tinders -Land that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the hotneowner. general contTactor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer:
-4-‘ ap.r1c[--
e - Print)
-- Signed)