HomeMy WebLinkAbout- Permits - 762 DALE STREET 10/2/2018 1
Commonwealth of Massachusetts 10404..Map Block-Lot
C0049
w BOARD OF HEALTH
Permit No
North Andover BHP-201s-o2ss
FEE
$175.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Chad Jablonski
to (Construct)an.Individual.Sewage Disposal System.
at No 762 DALE STREET
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as shown on the application for Disposal Works Construction Permit No. BHP-201.8-02a- 4atcd S em 2 18
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Issued On: Sep-25-2018 BOARD OF HEALTH
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���� TODAAP lication for Septic Disposal System
'S DATE
Construction Permit — T�� v� /� ����
$35O.DO-Full Repair �
NORTH ANDOVER, MA 01845 $175.0O-Component
Important* Application is herebv made for a permit to:
When filling Out [] construct o new on-site sewage disposal system*
forms vothe °
nompu��onv F] pai,orn*p|moeenoxinUngoo-nihoe��ugedim�naa|myntem
only the tab key sA� orrup|eneannx|atim8�y�t*nncnmponent-VVhmt?
*m"v*yvvr ^� �-.pair
curs m-uvnot
use the return A. Facility Information
key, ~16 ~`+
Address or Lot
2.-"*TYPE OF --SEPTIC SYSTIEW:
oi�m*n
, E] . ...' ff~.,.^/ (choose one) °^^
***If attach �do��permit to ����
> [ff Conventional System (pipe and stone system)
> El Infiltrator urB|odiffuawrK3m (Attach a copy of your oontifirahbn6o install this type ofoyaten.)
> Pressure Distribution @.A.S.(No D-Box}
-�- ------ ------�'--[l Pressure'Dosed,([-Bmmr Present)8.AcS.------ ��-�---------- '- � ------- - '
> [] Does the system require an effluent filter? You Nc���__
/f Yes, does plan specify make and model offilter? YES =/nohmfhor/nfm. negdem0
NO=(installer must specify brand of filter before DN/C issuance)
wha/isracMake? what is the
mw��
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Address(if different from above)
Owner Information
State ����
City/Town
Emoi|eduress Telephone Number
3. Installer Information ,
Name ,.
�� �� ,= ~,.,,,.',../
^1�
Address
76
ity[Town State Zip Code
Te—leph—on"e-N___—umber(Coll Ph on e#if possible please)
4. Designer Information,
cK�rowp State Zip Code
Telephone Number(Best#to Reach)
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«c~`=^�o. *c�'~~ Application for Disposal System Construction Permit^Page iof2
Application for Septic Disposal System
Construction Permit — TOWN O TODAYS DALE
$350.00-Full Repair
NORTH_ANDOVER, MA 01845 $175.00-Component t
PAGE 2OF2
A. Facility Information continued.... 1
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5. Type of Building: residential Dwelling or❑Commercial
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 ,rod v '" nd tand that until a final Certificate of Compliance has been issued by
h thi oard f H afi nstalled system is not approved. !! /
Name Date
i
Applica Ap a By: (Board of Health Representative)
__..._.._e ----
Nam °' Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Ptoject Maxiagex•Ohli�;atir)n Form Attached? Yes No
3. Pump Strstexn? Ifso,Attach-copy ?fFlectr call'exxnit Yes No
Applicaxitreceived copy of
".L7eetttcalluspectio.,rz Notes for Septic Systems" Yes _ No
l',
Handout?
4. Reviewed approvalletter, all paperwoxlfreceived?
5. FouAdatiox2 As-Built?(new construction only): Yes No
(Same scale as approved plan)
6. FloorPlarls?(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
(Engineer) t
Relative to the application oft4- i 1.�' s7c
(Installer's name) And dated +l 1 j✓�
Dated 9
( o a s cT.a—tiej— With revisions dated
(bast 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.prior to
performing any work on a site. I must have the approved pYans and the hermit on site when any work is
�ieing 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 am required to have:the necessary wonk completed prior to the applicable inspections as
indicated below. I understand that re-cl ection.without cc-repletion of thcitems in accordance
with Title 5 and the Board.of Health Re ilations rzlaMsult m a 50.UC1 fine being vied against me ancijor
my co:tnpany..
a. Bottom of Bed-- Generally, this is the first (1')inspection unless there is a retaining wall,which
should be done first. 1"he installer-roust request the inspection but does n.ot have to be;present.
b. Final Construction Ins pection-Engineer must first do their inspection. for elevations, ties, etc.
As-built of verbal OK (or e-mail to: healthdept@northandovernxa.gov) from the engineer roust be
submitted to the Board of health, after which installer calls for an inspection time. Installer must be
present for this insl'Dection. With a pump system, all electrical work must be ready and able to cause
pump to work and alarm to function.
c. Final Gracie--Installer:roust 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 (ather than simple ex.-avatim)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 insiall septic syst;e�r�s in North Anciovet- can constitute
reasons for
det7ial of the sac. ,and/or revocatiox_.�c�: suspension of my license to gpc rate in fhe Town of
North Andover,si�cant fxn�s to all t�er__� sos ztxvclv.ed are also possible.
5. As the installer, I understand that I must be on site daring the performance of the following construction
steps:
a. .Detetznvxatiorx th;2t the ptopet elevadotz of the excavatiatz has heen Leached.
b, lzzspection of the.sand attd stone to be used.
c. Fivalb7speetioti by Board ofLlealth staff ox-cotzsLdtant.
d. 1hstalladon of tank, .D-.Box,pipes, stane, vent,purnzp climber,.tetai ring wall and Other
comporzetzts.
6. As the :rasta�lc x, I tttzderstarzd i .1at I am solely responsible for 1.1 iizstallation._ f_the systexri as er the,
approved a:lans. No in.sttuctions lay the hatxieowner geaaeral contractoy.' _Mt y other persons._shall absolve
me of this obligation. c
"Undersigned Licensed.Septic Installer: 'spate)
ame-l:�iynt --- - - am i—e __ -
Town of North Andover
HEALTH DEPARTMENT
CHECK#: a.. DATE:
LOCATION: -.,
H/O NAME:
CONTRACTOR NAME:
Type of Permit car_Ki�qAse:(Check box)
0 Animal
El Body Art Establishment
• Body Art Practitioner
• Dumpster
0 Food Service-
0 Funeral Directors
• Massage Establishment
• Massage Practice
• Offal(Septic)Hauler
• Recreational Camp
• Sun tanning
• Swimming 11001
0 Tobacco
0 Trash/Solid Waste Hauler
0 Well Construction
SEPTIC�temss--
• Septic-Soil Testing
• Septic-Design Approval
Septic Disposal Works Construction(DW0 $
0 'Septic Disposal Works Installers(DWI)
0 Title 5 inspector
Title 5 Report
El Other. (Indicate)---
H alth Agent Initials
White-Applicant ye-Iloy)-Health Link-Treasurer