HomeMy WebLinkAbout- Permits - 920 JOHNSON STREET 10/17/2018 1
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Commonwealth of Massachusetts 107Ma ��oo>£_t.`ot 1
BOARD OF HEALTH Permit No
BHP-2018-0466
North Andover --- . ---- ----
FEE
DISPOSAL, WORKS CONSTRUCTION PERMIT
Permission is hereby granted Chad Jablonski
to(Construct)an Individual Sewage Disposal System.
at No 920 JOHNSON STREET
as shown on the application for Disposal Works Construction Permit Na BHP 201 - ated 'to 18
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Issued On: Oct-17-2018 BOARD OF HEALTH
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Application for Septic Disposal System
Construction Permit - TOWN OF TODAY'S DATE
$350.00-Full Repair
NORTH ANDOVER. IV 01845 $175.00-Component
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Important: Application is hereby made for a permit to:
When filling out El Construct a new on-site sewage disposal system* RECENED
forms on the
Computer,use E] Repair or replace an existing on-site sewage disposal system* OCT 17 2018
only the tab key E�rRepair or replace an existing system component-what.to move your
cursor-do not TOWN OF NORTH ANDOVER
use the return A. Facility Information HEALTH DEPARTMENT
key, q?- 0 � Q )A A-✓ 5'
Address or Lot#
City/i"own
2.-*TYPE OF SEPTIC SYSTEM':
> F1 Pump Fel Gravity(choose one)
***If pump s am, attach copy of electrical permit to application"*
> E,'rcc nvontional System (pipe and stone system)
> F1 Infiltrator or Blodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
> [:] Pressure Distribution S.A.S.(No D-Box)
> F1 Does the system require an effluent filter? Yes---,, No
Ifyes, 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 Me Model?
2. Owner Information
Name
Address(if riiifibrent from above)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
(2
ame Name of Company
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Address
12-1 Y.V
State Zip Code
Telephone Number(Cell Phon o#if possible please)
4. Designer Information
_f4-am, e Name of Company
Address
State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
Application for Septic Disposal System ___
TtJDA`C'S DATE
Construction Permit -- TOWN OF
Repair ANDOVER 01845 $7oo-Comon
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: [3f�esidential 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'[ nderstand that until a final Certificate of Compliance has;been issued by
this ar cif He th, the installed system is not approved.
f--
�"t
N i Date
App i Ap ve Y (Board of Health Representative
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Nam Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes V� No_
2. Pro'ectMarta ger Obli ation FofmAttaclzedP Yes No
3. I'm-aip Syste n? If so,Attach cvpY ofElectrical Permit off..
Applzcantxeceivecl copy of
"Electrical Inspection Notes fiat Scy)tic Systems" Ye�=—
FTanclout?
4. Reviewed appxoval.lettet, allpaperwork.-eceivecl?
5. Foundation As--Built?(new construction only): Yes— No ._.._._
(Saxxze scale as approved plan) -
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6. FlooxPlans?(new construction only): Yes _ No__..._._
Application for Dispersal System ConstrLICtlerrr Permit•Page 2 of 2
SEPTIC SYSTEM INSTALLER.PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic systeni for the property at:
q2_0 614jv.5�0'p "S 7
I Fox plan s by
(Address of septic system) (Enoieer)
Relative to the application of
name) And dated
(urignal date)
Dated 0 � I I I e_6 ( v
(Ioaay-s clate) With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, larn obligated to obtain all permits and Board of Health approved plans 71dor to
performing any work,on a site. I must have the approved plans and the Merit 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 ally
other person not associated with my company schedules an.inspection and.the system is not ready, then
item three shall be applicable.
3. As theinstaller,I arrirequired to have the necessary work completed prior to the applicable p plicable inspections as
indicated below. I understand that Le�iiesting an inspectionwithout corn si_ri accordance
with Title 5 and the Board of Health Reiilations may result in a150.00 fine being levied-avainst me and/or
a. Bottom of Bed---Generally, this is the first (I't) 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 Inspection—Engineer must first do their inspection for elevations, des, etc.
As-built of verbal OK (or e-mail to: healt-hdept@no:rtliandoveri.)aa.gov) from the engineer must be
submitted to the Board of Health, after which installer calls for an inspection
)ection time. Installer must be
present for this inspection. With a pump system, all electrical work iiiiist be ready and able to cause
putrip 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 work done by others unlicensed to install-septic systems in Nordi Andover can constitute
reasons for denial-of the system and/or tevocatioti-Q47-suspension of mv license to ot)erate in the Town of
North Andover
, fiqg,�toall persons involved are also possible.
—ossible.5. As the installer,T understand that Imust be on-site during the performance of the following construction
steps:
a, Determination that thepi-oper elevation ol'the excavation leas been teacbed.
b, Jnspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. .Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other
co'n1pollents.
6. As the installer. I understand that I ara solely responsible for the installationof the Vitem-aster Abe
approved plans. No insttuctions by the homeowner general contractor, gr any y a11 absolve
Ive
me of this Qtjtig
Undersigned Licensed Septic Installer: 2-o ay's ate)
C'
TNII-me-- rint) 19
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