HomeMy WebLinkAboutPermits - 257 BOXFORD STREET 7/30/2018 Commonwealth of Massachusetts
Map-Block-Lot
106 A0003
BOARD OF HEALTH _---....
Permit No
North And
BHP-2018-0227
P.L iu 4, ---_
.._
r FEF
F.1,
DISPOSAL, WORKS ONS`T'RUCTION PERMIT
Permission is hereby granted ,Chad Jablonski
to(Construct)an Individual.Sewage Disposal System.
at No 257 BOXFORI) STREET
as shown on the application.for Disposal Works Construction Permit No. BHP-2018- Dated my
. . . . .--- --
Issued On: Jul-10-2018 -------
BOARD OF--------
HEALTH
i
I
I
Application for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF
$350.00-Full Reair
NORTH ANDOVER., MA 01845 $175.00-Componpent
Important: Applicationis hereby made for a permit to:
When filling out E] Construct a new on-site sewage disposal system* pECENED
forms on the
computer,use [Repair or replace an existing on-site sewage disposal system*
only the tab key [] Repair or replace an existing system component–What? 2 t V1
to move your
cursor-do not
use the return A. Facility Information OWN OF wr'TH
key.
'3
. . ........
VQ. Address or Lot
JA V'J T>W�LC rc V0( !!S�
--EltyTownT-
&A 2.-*TYPE OF SEPTIC SYSTEM`:
> E] Pump ff Gravity(choose one)
"'If pump sxstem, attach copy of electrical permit to application"*
> UConventional System (pipe and stone system)
> El 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)
----------- --------
> [] 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 DWG issuance)
[moi at A the Ahikc?---.In,,it 1,v the M6del?_--,.--
2. Own er Information
Name
-kddke:s-s(if—different from above)
----------
Ultyfiown State Zip Code
—Teleplion—eNumber
3. Installer Information
C/t,•-t' r"�''—C'"✓
Name - Name of Company
..........
Address
------ -------
City/Town State Zip Code
ek-kN 0 C5, e"
Telephone Number(Cell Phone#if possible please)
4. Designer Information
5V I
Name
Name of Company
Address
-City/Town State Zip Code
-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
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
PAGE 2 4F -2 ---_
A. Facility Information continued....
5. Type of Building. EIR' esidential Dwelling or nCommercial
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
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. 1 understand that until a final Certificate of Compliance has been issued by
this oar o, Ith, the installed system is not approved.
?
Nh date
Applic i App v d y: (Board of Health Representative)
Name date
App icati Disapproved for the following reasons:
For Office Use Only:
1, Fee Attacbed? Yes No
2. .1?toject Ma.naget•Obiigatio r Form Attached? Yes No
3. Primp Sys-tem? If so,Attach copy ofEleetezcal Permit 11'es No
.Applica.nt.received copy of
"Electitcallospectivti Notes forSeptic Systems" Yes_ No�
Flandout?
No
4. RerTie'<ved tzppt-ovallettet, allpapettivotic.tecetveo'. Yes_._._.._
MISsiag.. _--- -------
A.
--A . Foupdatiotz.As-Bailt?(new construction only): Yep No
(Same scale as apptovedplan)
G: Floot•.I'Lms?(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
(Fng-neer)C
Relative to the application of e,3
(Installer's name) And dated
n�rna ate
Dated e, With revisions dated k e,
(I oday's date) (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 p1lot to
performing any work on a site. I must have the approved plans and the permit on 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 company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer,I and r
.equited to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an isispe
qtionwiffiout comt�letion of the ite;rns in accordance
with T1t_k 5 and the Board of Health Regulations May QQ fine being levied against me eand or
91-y—tom PALly--
a. Bottom of Bed Generally, this is the first (Vinspection-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. Final Construction Ins pecti(gi Engineer must first do their inspection for elevations, des, etc.
As-built of verbal OK (or e-mail to: healthdeptoy northandoverma.goy) 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,1.understand that only I may perform the work (otber Haan siviple 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 sy
At
�enks in NotthA
md.over can constitute
reasons for denial of the system andL Li s
QtrevocationorsusDe _1QqofMVhcet1sc the Town of
_.Q�hc�,e to DV(zi:ate in the
North AndovetaigWficant fines to all-D-ersons involved are also possible.
5. As the installer,I understand that I must be on-site during the performance of the following construction
steps:
2. Determination that thepropel-elevation of the excavation has been reached.
b, Inspection of the sand and stone to be used.
c. Final inspection by,Board of11c�altb staff or consultant.
d. Installation oftan1c, D-Box,pipes, stone, vent,pump cliambe-t, retaining wall and other
componetits.
6. As the installer .1 understand that 1- for the—installation of the systc=as p�er_tbe
approved plans.. No instructions by the homeowner, general conttactor, or any other persons shall absolve
me of this obligation.
Undersigned.Licensed Septic Installer: 7 b (T day's Date)
-(Name—Print) 19
�==== --rr'---- =====� Health ____ Treasurer