HomeMy WebLinkAboutPermits - 265 HAY MEADOW ROAD 8/6/2018 � Map-Block-Lot
104 B0085
% f i, •„
Commonwealth oMassachusetts
BOARD OF HEALTH on'�T, Permit No
fan �w,
BHP-2018-0236
North And ov a - --_-.
PA. FFF
F.I. $175.00
—..,.,, ------..._..
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted a�7___.� ,_ _ r_Y�� CO—� �---" ��� '�. -------
to(Construct)an Individual Sewage Disposal System.
at Ido 265 HAY MEADOW ROAD
as shown on the application for Disposal Works Construction Permit No. 131-IR-2018-11ated -
Issued On:Jul-19-2018 BOAIU)OF HEALTH
Application for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF
$350.00-Full Repair
NORTH ANDOVER2-MA 01845 $175.00-Component
Important: APAIIgfiaon s_herob maam :
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use El Repair or replace an existing on-site sewage disposal system*
161
only the tab key WR-e*pair or replace an existing system component—What?
to move your
cursor-do not
use the return A. Facility Information
key. RECEIVED
Q
Address or C�t#
—---------
67it—yFTown TOWN OF NOFM-1 ANDOVB ,
2.-*TYPE OF S—EP11b SYSTEM*: 11EALT H DEPARTMENT
> E] Pump UKravity(choose one)
***If purrip,sy�lem, attach copy of electrical permit to application'
> conventional System (pipe and stone system)
R Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
F1 Pressure Distribution S.A.S.(No D-Box)
1..-,-,---,--,..."---.�-.-��--�--,---.-)�,-----El-..Pressure-Dot�ed,-(D,�8o)cPresor-it)-Sl-.A-:S-.------,-----'--7'--____ ----- --------
> 0 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 DWC issuance)
What is the What is the Model?—____-
2. Owner Information
a
Nam
Add2e;ss(if"different ab
Cityl-Fown State Zip Code
_. ..-
Email Waddt:es.- Tele
hone Number
3. lnstWJer Informatipp
NameName of Company
Cit own AddAre
State Zip Code
—Telephone umber(Cell Phone#if possible please)
4. Designer Information
_i4_arneName of Company
Ad—dre—ss
—
wrl 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
NORTHANDOVERI- 01845 $175.00-Component
-A_GE 2---OF 2
A. Facility Information continued....
5. Type of Building: OResidential Dwelling or[]Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal syst n in accordance with the provisions of Title 5 of the
Environmental Cod ,as we as the Local Subsurface Disposal Regulations for the Town of
North n ve . I n ist nd that until a final Certificate of Compliance has been issued by
this ar o ea h installed system is not approved.
Date
Ap /,q)
I [on proved y., r senta
'
C
me Date
Application Disapproved for the`f llowing reasons:
For Office Use Only:
1. .Fee Attached.? Yesor
2. PiqjectManager ohUgation Farm Attached? yes No
3. Pump.6 stetn? Ifs o,A ga k_jjqjZy
_qfLUe
init Yes_--_ No
Applicant-received copy of NX
Notes for Septic Systm.1s" Yes
Handout?
4. Reviewed approval letter, allpaperworkreceived? Yes Na___...
Mis
S. BoundadonAs-Built?(new construction only): Yes N)(
(Same scale as approved plan) -
6 Moorpjaos?(new construction only). Yes NJ(
Application for Disposal system Construction Permit-Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT' MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the struction for the septic system for the property at:
17 12-
Fox plans by
tic syst
(Address of septic sys (engineer)
Relative to the application of
(Installer's narne) And dated
Dated 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 pt o to
, jT
performing any work on a site. 1.triust have the approved plans and the perrrxit on site when any work is
beine;_dcqie.
2. As the installer, I must call forany 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
iterri 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 tequestfngainspection,W1irt1f1ouTt COT-npletion of the items—inaccord-a-nce
with Title 5 and the Boardof Health Regulations may result in a . 50.00 fine being. ied__gg�:tnc end/or
my-c
a. Bottom of Bed- Generally, this is the first (15), inspection unless there is a retaining wall,which
should be done first. The installermustrequest the inspection but does not have to be present.
b, Final Construction ltjspcctioti-Engineer must first do their inspection for elevation,,.,, ties, etc.
As-built of verbal OK(or e-mail to: heal.didept@no-ttliatidaverma,gov) ftorn the engi-necTraust be
submitted to the Board of Health, after which installer calls fox 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 GradeInstaller must request inspection when all grading is coin
pletc. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (abor tbansbvple excaiwfion)and I a.rarequired
to complete the installation of the system identified in the attached application for installation. I further
understand that work done beat 'anlicensed to install septic steins * North.Andover can constitute
t in 11 SCRU—s-y
reasons for denial,of the -Y
_�stKm,and r-revocation or suVension of 1-QL in hcgtise�este iia the Town of
North Andover ificant ftRe�
,-sign tQg� n
ersos involved are also possible.
_ -_ —
5. As the installer, I understand that I must be on-site during the perforn3ance of the following construction
steps:
a. Detennination that thepi-opar elevation of the excavation has been-teacbed.
b, Inspection of the sand and stone to be used,
c. Finalinspection by Boai-d of Health staffor consultant
d installation of tankD-Box,pipes, stone, vent,pump cliambat, I-etainihg wall and other
COMPO'Vents,
C. As the installer.j,undersn
tax n the installation d that I at solely res o sible for
,,.the
h homeowner,rove ans. No instructions contractor, Lary other persons shall absolve
..��uuctio�ns4y__th.e ho:tneo 1 er general contrac
:roved
me of this ghligation.
(To ay's Date)
Septic IJ
Unde-tsigned Licensed Sep --Installer:
Le e
A&
_�(Naiye- �rint) me e
�orerH d' U wbwT
Town of North Andover
Town of North Andover
HEALTH DEPARTMENT
HEALTH DEPARTMENT
CHECK#-Z2 '2 DATE:
kJ CHECK#: DATE:7
LOCATION: 0 U-)
LOCATION: .2 2
z"
H/O NAME: H/0 NAME: 5 e
CONTRACTOR NAME- CONTRACTOR NAME:
L
Type��1 ermit or License: (Check box) Type of Permit or License:(Check box)
0 Animal 0 Animal $
• Body Art Establishment $ 0 Body Art Establishment $
• Body Art Practitioner 0 Body Art Practitioner $
• Dunipster 0 Dunipster $
• Food Service-'rype:-----.- 0 Food Service-
0 Funeral Directors $ 0 Funeral Directors
0 Massage Establishment $ 0 Massage Establishment
0 Massage Practice $ 0 Massage Practice
0 Offal(Septic)Hauler 0 Offal(Septic)Hauler
0 Recreational Camp 0 Recreational Camp
0 Sun tanning $ 0 Sun tanning
0 Swimming Pool 0 Swimming Pool $
0 Tobacco $ 0 Tobacco
0 Trash/Solid Waste Hauler 0 Trash/Solid Waste Hauler $
0 Well Construction $ 0 Well Construction $
SEPTIC��ems.- SEPTIC S�eins:
u septic-Soil Testing 0 Septic-Soil Testing $
0�
0 Septic-Design Approval $ 0 Septic-Design Approval $
Septic Disposal Works Construction(DWQ
Septic Disposal Works Construction(DWQ $,0Q $
• Septic Disposal Works Installers(DWI) $ IJ Septic Disposal WorksInstallers(DWI) $
• Title 5 Inspector $-- 0 Title 5 Inspector $-
• Title 5 Report $- 13 Title 5 Report $
• Other. (Indicate)-- $ 0 Other. (Indicate).,.,-,---,-- $
Agent Initialsi h6lth Agent Initials
White-Applicant Yellow-Health Pink- Treasurer 1 White-Applicant Yellow Health Pink- Treasurer