HomeMy WebLinkAbout- Permits - 43 OXBOW CIRCLE 10/17/2018 1
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Commonwealth of Massachusetts Map-Block-Lot
BOARD OF HEALTH Permit No
North Andover BHp-zals-oas
FEE
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DISPOSAL, WORKS CONSTRUC'T'ION PERMIT
Permission is hereby granted John_L. DiVincenzo
to(Construct)an Individual Sewage Disposal System.
at No 43 OXBOW CIRCLE
as shown on the application for Disposal Works Construction Permit No BI^IP 2018 ed ob 18
Issued On: Oct-15-2018 BOARD OF HEALTH
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Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
$350.00-Full Repair
NORTH ANDOVER, mA 01845 $175.00-Component
—----------ft f-- -
Important: Application is hereby made for a permit o:
When filling Out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use E] Repair or replace an existing on-site sewage disposal system*
only the tab key /) -r-
[BlIepair or replace an existing system component What?,. 5_Az!L�_" T
to move your
cursor-do not
use the return A. Fadlity Information
key.
Address or Lot#
IV
City]Town
2.-*TYPE 0FSEPT_1_"Y_STEM*:
E] Pump L3-G-ravity(choose one)
"If pump syyom,-attach copy of electrical permit to application***
> E41Conventional System (pipe and stone system)
� 0 Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
> [I Pressure Distribution S.A.S.(No D-Box)
--�-----EI-Pressure:-Dused,(DKBox-Preseiit)-S-A-.S-.7------.,----7,-------
)� El 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)
Miat is the Make? ___IWIqt jo,die Model?--____
2. Owner Information
Name
Address(if different from gBove)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
Name Name of Company
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Addr s
90, eul-4241-
V
CitylTown State Zip Code
-Telephone N_urri6a(Coll Phone#Wpossible please)
4. Designer Information
Name Name of Company
Z�ity_fr n 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. 01.845 $75.00-Component
PAGE2—OF 2
A. Facility Information continued....
5. Type of Building: DResidential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage dis at system in accordance with the provisions of Title 5 of the
Enviro me tat C e, as well he Local Subsurface Disposal Regulations for the Town of
JV
vorttfl, n ov r. u erstC that until a final Certificate of Compliance has been issued by
this poa d He 1 , th installed system is not approved.
L-Al
Dat
A li �,..
p p oved B and o alth ep
_.__ ---
Application Disapproved for the following reasons:
For Office Use C)nly:
1. Fce Attached? Yes _ No
2. PxajectMauagee Oblig-atiorz Farm Attached? Yes__--_-, No
3. Pump S sy term? Ifsa,Attach ca !?fElc ctrfcalPettn t Yes
Applicatzt-received copy of
'EleetJtcal.Inspectta-z.Natcs fo- Septic Systems'' Yew No
IIa-tdozzt?
4.
lette-• all a
.Revzewed apptoval , etwatkxecerveda Yes p p
5. Fou-zdatioxz As-wilt?(new construction only): Yes No
(Sa-ne scale as apptoved plat-)
G: Floo.r.Plaris?(new construction only): Yes._.._.__ Ns_
Application for Disposal System construction Permit•Page 2 of
SEPTIC SYSTEM INSTALLER PROJECI' MANAGEMENT OBLIGXrIONS
As the North Andover licensed installer for the construction.for the septic system for t-he property at:
J
(Address of septic system) For plans by
(Engineer)
Relative to the application of
(installer's name) And dated r
rrgzna ate
Dated `�� With revisions dated
a ay 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 prior to
performing any work on a site. I must have the approved platls and the peramrait_on site when arxy worth is
l?ein cg lane.
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 tile,system is riot ready, then
item three shall be applicable.
3. As the installer,1. am.required to have the necessary work cotrxpleted prior to the applicable inspections as
indicated below. I understand that_requesw?-an inspection without ecarnpledon of the items in accordance
with Title 5 and the Board of Health Regulations my result in a$50. 0 fine be levied against me and/or
mycompany.
a. Bottom of Bed— Generally,this is the first (Vt) 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 Ins ectiotx _.Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OIL (or e-mail to: health t-h dept@norandoverirxa.gov) 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 arid alarm,to function..
c. Final Gracie—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 (Wer djan sb;;ple excavatim)and I am:required
to complete the installation of the system identified in the attached application for installation. I fitther
understand that world curie by others unlicensed to install septic systems in North Andover can constitute
reasons for deniaLof the system ancl/ revocatiorx or suspension of rxxy license to operate.i:rx th,e'I'0" of
North Andover significant fines to all persons itxvalvc_a e also possible_,
5. As the installer, 1 understand that l must be on-site during the performance of the following construction
steps:
a. Detettnination that thel-7roper elevation of the excavation has been readied
b. Inspection of the sand and stone to be used
e, Final inspection by Board ofllealth staff or consultant.
d Installation oftank, D-Box,.pipes, stone, vent,pump cliamber, seta%niog wall and othel,
components.
6. As the installer,_):understand that I arri solely responsible for the installation of the system as per the
appravecl plarxs, No i lstmuctiorxs by the harneowrxex,gene_tQ_contractor, or arty ether persons shall,absolve
me of this obligation. J
Undet:signed Licensed Septic Installer: (To 's D
ame--liirxt ame— ignec
a a' �
o �
Town of North Andover
, a HEALTH DEPARTMENT
CHECK.#: DATE: d
LOCATION.
" " 1
H/O NAME: � .� �� ) �. Uzi
CONTRACTOR NAME:
Type of Permit or]License: (Check boas)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-,Type: $—�,
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $,
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEP77C Sustems.
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other.(Indicate). $
1",
He h Agent Initials
White-Applicant Yellow-Health Pink d Treasurer
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