HomeMy WebLinkAbout- Permits - 521 SALEM STREET 2 10/22/2018 Commonwealth of Massachusetts Map-Block-Lot
/%f °%�/°l �• 038 00008
BOARD OF HEALTH - - -
� E'ermit No
North Andover s" --zO1a-02 2
FEE
$350.00
---------------
DI;aPOSAL WORKS CONSTRUCTION PERMIT
Perrnission is hereby granted James Heider
to(Construct)an Individual Sewage Disposal System.
at No 521 -S LEM STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2018-02 aced ' ernr 1 018
-- ----------------. _.....
Issued On: Sep-17-2018 BOARD OF HEALTH
i
1
i
Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TO" OF
$175
.00 Full ReairNORTH ANDOVER MA 01845 00-Component
Important: Application is hereby made for a permit to:
When filling out E] Construct a new on-site sewage disposal system*
forms on the RECEIVED
computer,use )K Repair or replace an existing on-site sewage disposal system*
only the tab key
to move Your El Repair or replace an existing system component—What?
Cursor-do not
use the return A. Facility Information
key. C" I "TOWN 01�,'NMTH ANDOVER
H 2EPARI MOO`
Address or Lot#
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
> [] Pump Gravity(choose one)
***If pump system, attach copy of electrical permit to application'
> R Conventional System (pipe and stone system)
> F-1 Infiltrator or Blodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.)
> F1 Pressure Distribution S.A.S. (No D-Box)
V
> [] 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)
Wliatis the Make?....... Whatis the Model?_.—__-,
2. Owner Information
�e-f ;�,r eA, �f!,j.........
Name P t
-AJ
Address(if different rorn above)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
-ZliAM-41-1—S i) z_Xs�ec
Name Name Cam an py
,2 --------------
Address
A,
CityF['own StaCte Zip Code
C c/'7
I eleph;Waw_nber(Coll Phone 4 if possible please)
4. Designer Information
,c�i
-Nane Name of Company
Address
City/Town State Zip Code
1'elephone Number(Best 0 to Reach)
Application for Disposal System Construction Permit-Page I of 2
}
Application for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF
$350.00-Full Repair
NORTH ANDOVER. MA 01845 $175.00-Component
i
PAGE 2 OF 2 _
I
A. Facility Information continued....
5. Type of Buiidlnq: (residential Dwelling or❑Commercial 1
G. 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 At ver. I understand that until a final Certificate of Compliance has been issued by
this oard f Health, installed system is not approved
�'
le Date
Ap li ti Approve By Bo th epresentative)
Marne Date
Application Disapproved for the following reasons:
For Office Use Only
.1. Fee Attached.? Yes No
tclect Marza�n-ei•C7b �2. I' Xz atioo fibifn Attached? Yes l/ No
3. _Puxrp Syy etn? If so,Attycb copy of.E'leeVicalPetm t Yes NO
Applicaizt-teceived copy of
"1 "leetrical fnspectio_n Notes for Septic Systems" Yes No,
.Hai clozzt?
4 Refdewedapptoval-letter, allpape-Fvoikxeceived? Yes NO
Missr`t�g.
5. Fozwdatioa AsBuilt?(new construction only): Yes No
(Same scale as app-toved plan
)
G. Floot•Plaps?(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:
C—/ SJOZILOI
(Address of septic system) For plans by 0
(Engineer)
Relative to the application
ofW e��sta er's name)e)� Arid dated
Dated
With dated
�ays afi,7— (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 Jot to
performing; ie _p qy-)y(�ikis
any work on a site. I must have d
approved acid
site when q
being done,
2. As the installer, I triust 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 understand that requestitag hout completion of the Sterns in accordance
-without cot-_.,--
wida Title_5 and the!ALqxtof Health Rc,gEdations tnay a e cult in a
450.00 fine being 1evicd_againA_Wc and or
giy g nipqny_
a. Bottom of Bed—Generally, this is the first (1'� inspection unless thew is atetaining 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, ties, etc.
As-built of verbal OK(or e-mail to: healtildept@noitharidoverma-gov) from the engineer mustbe
submitted to the Board of Health, after which installer calls for an inspection time. Installer rrilist 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 t a am.- uir
may perform the:work (other than sii)�ple excavation)and I req ed
to complete the installation of the system identified in the attached application :Ear installation. I further
understand that work done by others unlicensed to install septic systems in North_Andover ckrj constitute
reasons- for denial of the Wstem arid/or revocation or suspension of my license to operate J11-the—Town of
North Andover.,,sigdficaritfiticiig-all 4ic� sons involved are also ssibt(,
5. As the installer,I understand that Irnust be on-site during the performance of the following construction
steps:
a. DetaTn2itiation that the proper elevation of the excavation has been reached.
b, Inspection of the sand and stoneto be used.
c. Final inspection by Board ofHealth staffor consultant.
d. Installation of tame, D-Box,pipes, stone, vent,pump cliambat, retaining wall and other
cotriponents.
e 1 as tamer 6. As the installer I understand that lam solely rest) far or the of the-systen
Ls-by Ll&homeown�LiMiiLital contractor. or 2,11
-4 p p-r cr V e_-_C1 laps.--_N_0-in-S_ttuctioi
y other persons shall absolve
me of this-pbligation.
Undersigned Licensed Septic Installer: (roday's Date)
�Ta M 'S d_ r
�Narii(�-Pa�'M7_l e igne
Town of North Andover f
HEALTH DEPARTMENT
34CHWs��
CHECK ii: l�?) ,,. DATE: V
m 1
LOCATION:
H/O NAME ;,.W
"V
CONTRACTOR NAM
E
Type of Permit or License:(Check box) �
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service_Type:��_�� .,..W _ — $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)hauler $_
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $_
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
Septic Disposal Works Construction(DWC) $ Iflic) =
Septic Disposal Works Installers(DWI) $
❑ "Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate),.,,... _. $
He °lt*Agent Initials
White-Applicant Yellow-Health Pin&- Treasurer