HomeMy WebLinkAboutPermits - 55 FARNUM STREET 7/30/2018 Commonwealth of Massachusetts neap-Block-Lot
' 107.A0056
BOARD OF HEALTH _.-------.
Permit No
North Andover BMP-2018-0235
P.I. - ------
FEE
F.I.
$175.00
DISPOSAL, WORKS CONSTRUCTION PER
Permission is hereby granted
r
to(Construct)an Individual Sewage Disposal Systern.
a„
at No 55 FARNUM STREET
as shown oil the application for Disposal Works Construction Permit No. BIIP-2.018-0235 ted JulI$
Issued Un: Jul-19-2018 BOARD- F HEALTH
1
Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
$350.00-FLIII Repair
NORTH .ANDOVER., MA 01845 $175.00-Component
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms an the
computer,use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key "d Repair or replace an existing system component—What?
to move your
cursor-do riot
use
e the return aclInormation
key.
'
Address or Lot#
City/Town
ll
2.- `TYPE OF SEPTIC SYSTEM*: _ -_._. ��� 4 ��"k ���� ���
9 ❑ Pump ❑Gravity(choose one)
***If pump system,attach copy of electrical permit to application***
p E°Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
Y ❑ Pressure Distribution S.A.S.(No D-Box)
_._❑-PI°essurerposed(D=BuxrPresent)_S,.A.S _,._..
➢ ❑ Does the system require an effluent filter? Yes Na
If yes, does plan specify make and model of filter? YES =(no further info. needed)
IVO=(installer must specify brand of filter before DWC issuance)
What.is tlrelflalee? � _. what is the odeL>.__,_.____----� w.
2. Owner Information
....._._ x _ _ __-_-__..
Name
Address(if differen frornWa ove)
City/Towr7 State Zip Code
Email address Telephone Number __..
3. Installer Information
Name Name of Company
Address ..
City/Town State Zip Code
reiephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
AddressY -
Cityliown State Zip Code
j Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Application for Septic Disposal System TODAY'S-DATE
Construction Permit - TOWN OF
�17oo-
0Full pnetNORTH
eANDOVER, MA 01845 5Comon
PAGE 2 OF 2
A. Facility Information continued ...
5. Typeof BLdIdIng: V� (�esidenfial Dwelling or[]Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage 'sposal system in accordance with the provisions of Title 5 of the
Env rot nenta Ce;� 11 as the Local Subsurface Disposal Regulations for the Town of
No h ,nd e _� ell
that until a final Certificate of Compliance has been issued by
th' B a of I h,'t6einstalled system is not approved.
.pate
ry
..A
p atio 1 pprov d ,.-JB and of _e_qltk Representative)
me Date7
Application Disapprove dfor fh6 ollowing reasons:
For Office Use Only:
1. FeeAttachcd? Na
Yes__ No
3. Purrzz S sem? Ji'so, No
Applicant-received copy of
1W.11ecidealInspecdo,n Notes fo-i Septic Systems" Yes No
Handout?
4. Reu4ewcdapptovallettei; affpapat-wosk-teccived? yes No,,-,
.5. EovodatjopAs-Built?(new construction only): Yes No
(Sarre scale as appi-o vedplaq)
6. Doo_eHans?(new construction only). yes No
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:
(Address of septic system) For plans by
(Engirxeer) �
Relative to the application of
(iststaller.'s name) .And dated
rlgina ate
Dated
G '
oc ay s c ate With revisions dated
(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 plos to
performing any work on a site. I must have theapproved plans and the perlr-it on site when anywork his
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 rely company schedules an inspection and the system is not ready, theta
iter-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 inspc c tion without completion of the items in accordance
with Title 5_and the Board of Ilc,alth Ire uttc�rls txtay result in a$50.0 Etre being levied against me incl/or
m�cot�pat�.
a. Bottom of Bed--- Generally, this is the first (15)inspection unless there is a retaining wall,which
should be done first. `:l'he installer must request the inspection but does xlot have to be present.
b. Final Construction Inspection—Engineer rrlust first do their inspection for elevations, ties, etc.
As-brrilt of verbal.OK (or e-innail to: healtlidept@nortlaa;ndoverlrla.gov) f.orrr 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 primp system, all electrical work must be ready and able to cause
pump to worst`and alarrrr 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 perfornl the wo.rlic (other than simple excrzvecta,'on)and I arxn required
to complete the installation of the system identified in the attached apl..)hcadon for installation. I further
understand that work done ley others unlicensed to--nstallse tic 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 caf
Norah 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. Detertnivation that the proper clevation of the excavation has been reached
b. Inspection of the sand and stone to be used
c. -Einal inspection by Board of Health staff or consultant.
d. IrxstaPation of tank, D-Box,pipes, stone, vent,pump cliambet, retaininxg wall and other
compo-Dents.
6. As the installer,I understand that I_am.solely responsible for the installation. ofMie system as pei�the
approved plays. No instructions by the homeownex,., shall absolve
me of this obligatioix.
Undersigned Licensed Septic Installer:
: da s to)
I �Ce
(Name-Print) ame- / l
t "
mry
,LORTH
kd Vk0RT*j
Town Town of North Andover
of North Andover
HEALTH DEPARTMENT HEALTH DEPARTMENT
A
el ACHU 0,.0
DATE:
CHECK#: 7 DATE: /;R CHECK#: Z
. . .............
LOCATION: .e
LOCATION: ..�)
H/0 NAME: hot"", /ol H/O NAME:
CONTRACTOR N A E: .�,.
CONTRACTOR NAME:
L
Type of Permit or Licen2t: (Check box) Type of Permit or License: (Check box)
• Animal 0 Animal $
• Body Art Establishment $ 0 Body Art Establishment
• Body Art Practitioner $_ 0 Body Art Practitioner
0 Dumpster $ 0 Dumpster
• Food Service- 0 Food Service-
• Funeral Directors 0 Funeral Directors;
• Massage Establishment 0 Massage Establishment
• Massage Practice $ 0 Massage Practice $
• Offal(Septic)Hauler 0 Offal(Septic)Haider
• Recreational Camp 0 Recreational Camp $
• Sun tanning $ 0 Sun tanning
• Swimming Pool 0 Swimming Pool
• Tobacco 0 Tobacco
Ili
• Trash/Solid Waste Hauler 0 Trash/Solid Waste Hauler
• Well Construction 0 Well Construction
SEPTIC Uslems, SEPTIC Systems.
• Septic-Soil Testing $ El Septic-Soil Testing $
• Septic-Design Approval $ 0 Septic-Design Approval
M k) $
Septic Disposal Works Construction(DW0 $5"(0
Septic Disposal Works Constniction(DWQ
0 Septic Disposal Works Installers(DWI) $ 0 Septic Disposal Works Installers(DWI) $_
0 Title 5 Inspector 0 Title 5 Inspector $—_
0 Title 5 Report $ 0 Title 5 Report $_
0 Other. Undicatet, -(Indicate)—.-----.
0 Other. $
........ ... ....
Healift-Agent Initial., He`41th,Agent Initials'.
White-Applicant Yellozy-Health Pink--Treasurer White-Applicant Yellow-Health Pink-Treasurer