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HomeMy WebLinkAbout- Permits - 79 ROCKY BROOK ROAD 9/18/2018 • • Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALTH - ------------- * Permit No North Andover BHP-2018-0280 FEE $175M DISPOSAL, WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd f3ateson to(Construct)an Individual Sewage Disposal System. at No 79 ROCKY BROOK ROAD ------------ as shown on the application for Disposal Works Construction Permit No. BHP 2018-02 ated S . em r 1 018 Issued On: Sep-18.2018 BOA D OF HEALTH i i 1 1 Application for Septic Disposal System _-- TODAY'S DATE Construction Permit -- TOWN OF $350.00-Full Repair NORTH AV VVLR, � A 0 845 $175.00-Component c Important: Ayyiication is hereby made for a permit to. When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use ❑Repair or replace an existing on-site sewage disposal system* only the tab key 03iiepair or replace an existing system component—What? to move your cursor-do not use the return A. Facility Information / key. Address or Lot# City/Town 2.-*7YpE OF SEPTw,IC SYSTEM*. > ❑ Pump Gravity(choose one) ***If pump system,attach copy of electrical permit to application*** ➢ ❑Conventional System (pipe and stone system) ➢ ❑ 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) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. Y ❑ 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.&the Make? Wbatis the Model? 2. Owner Information --- Name _ Address(if different from above) _r City/Town State Zip Code -- Email address Telephone Number 3. Installer Information _ /�^ �'• ., BA '+' �f]At.-TN-TE RISES,-IN ------ Name Name of Company -- /fir' /f✓��1 . ,. - 111 Ao illa 12nad ------ — Address — --� Andover MA 0181.0 City/Town - State Zip Code Telephone Number(Ceff Phone#if possible please) 4. Designer_Info rmation Name _ Name of Company _ Addross City/Town State _ Zip Code - Telephone Number(Best#to(teach) _ Application for Disposal System Construction Permit•Page 1 of 2 «� •. Application for Septic Disposal System Construction Permit - TOWN OF TgDAY'S DATE $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type Of Buildinq: 3<esidentlal 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 Andover. I understand that until a final Certificate of Compliance has been issued by installed system is not approved. � d this Board of H alt ._ „ �"!ns Name , "" Date p 7rd presentativeli � n A� rov d of alth Re a Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached.a Yes No� 2. Project Manager Obligation Form Attached? Yes V1 No� 3. Primp System? If so.Attach co y ofElectttcal Permit Yes;_ No Applicant received copy of "Electticallaspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approvadletter,all paperwork received. Yes No Missing.• 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 rt SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: For plans by Relative to the application of And dated mwne) ((ht'glm C a (e) Dated With revisions dated J"Udy c6sed(Lite) 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 pfiox to performing any work on a site. I must-have the_"rq when any worl�is 11eing-dcane. 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 prior to the applicable inspections as indicated below. I understated that requesting.an ins ect�ionwi Accordance with Title 5 and the Board of health Re, fine being levied--againstme.�and or. my—cQW41an 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. Final Construction Inspecti —Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK(or e-mail to: "I.1ol ­i(,I frorn 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_Nyork done 4 !ed���syste is in North Andover can constitute reasons for denial of the Mstemand/or revocationQLsuspension.of my license to oberate ire the Town of North Ando-vctsignificant fines to all persons involved are WsQ_p-Qssible. 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. d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer I understand that I a-- -responsible for.1he installation:of the system as per the app roved plans o_instructiqtj5 by the homeowqcr,general contractor or any other persons shall absolve me of this ob]iLxaqQn. Undersigned Licensed Septic Installer: (h)day',,; I-Xite) yJ Tmine­- Print) ned),­ 04, Town of North Andover HEALTH DEPARTMENT CHECK#: Q 9 DATE: gcwe LOCATION: nc 1-1/0 NAME: -L) CONTRACTOR NAME--", � Twe cif or License: (Check box) 0 Animal $ • Body Art Establishment • Body Art Practitioner $ 0 Dumpster • Food Set-vice- • Funeral Directors • Massage Establishment • Massage Practice $ • Offal(Septic)Hauler $ • Recreational Camp $--.— • Suit tanning $ • Swimming Pool $ 0 Tobacco $ • Trash/Solid Waste Hauler $ • Well Construction SEPTIC Susteins: • Septic--Soil Testing $ • Septic-Design Approval $ kSeptic Disposal Works Construction(DWQ $ * Septic Disposal Works Installers(DWI) $ * Title 5 Inspector $ 0 Title 5 Report $ [J Other. (Indicate)—.—,— $ Health Agent Initials M6kiLe-Applicant Yellow-Health Pink-Treasurer