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HomeMy WebLinkAbout- Permits - 350 SUMMER STREET 10/23/2018 �w _..—. _.,.. ... - - _ ........ ---.-- ... NO, �1, ,, Commonwealth of Massachusetts Map-Block-Lot * 107.A0162 BOARD OF HEALTH .. -------- ~ Permit No North Andover BHP-2018.0461 FEE $175,00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Daniel A. Giard ------------------------------ to(Construct)an Individual Sewage Disposal System. at No 350 SUMMER STREET as shown on the application for Disposal Works Construction Permit No. BLIP-2018-046 ted O ( ,20 Issued On: Oct-09-2018 BOAR OF HEALTH � . Application for Septic Disposal System T:© 501 TE Construction Permit — TOWN OF -Full Repair NORTH ANDOVER, MA 01845 $175 oo-Component I Important: Af�plicaton is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use rRepair pair or replace an existing on-site sewage disposal system* only the tab key or replace an existing system component—What? to move your cursor_do not use the return A. FaGility Information key, _ Addre� "J r r Lot# - _ a City/Town t Rake rB n 2.-TYPE OF SEPTIC_SYSTEM_*__: _ ➢ ❑ Pump ❑"Gravity(choose one) ***If pumps tem, attach copy of electrical permit to application*** > ' Conventional System (pipe and stone system) 9 ❑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)> ❑ Does the systern 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) TrIbatis the Make?- _..__.... Wlbatis the Model?_.,_. -.____ 2. Owner Information Name Address(if different from above) Cityrrown State Zip Code all address telephone Number 3. Installer Information i ::..,..__ 6 J Name Name of Company j Address Cityrrown _. State Zip Code a, w "i', Telephone Number(Cell Phone#if possible please) 4. Designer Information Warne Name of Company Address^ Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 ( "Z _X1 0 AakApplication for Septic Disposal System TODAY'S DATE Construction Permit - TOUN OF $350.00-Full Repair NORTH ANDOVE% MA 01845 $175.00-Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Buildin : oResidential Dwelling or[]Commercial al 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 this Board of Health, the installed system is not approved. Name Date ------—-------- Applic- n A d By: (Board of Health Representative) 'c Na e - Date Application Disapproved for the following reasons: For Office Use OnIV: V/ 1. Fee Attached? Yes___._. 2. I-IrojectMaiiage-t Obligation Foftn.Attael3ed? Yes .— No .3. �''urp,S%�tm? If so,Attach cofyv of.131ectrical Pely),,Vt 'Yes-.— Na.. �_ AppEcantteceived copy Of IT.,j,ectjjcaj inspection Notes for Septic Systems" Yes No4 Handout? 4. Reviewedappfomqlfctter, allpape-tivofkfeceived? Yes No .5. Foundation As-Vuilt?(new construction only): Yes" No (sa-Me scale as;apptovedplan) G. FJoorPlans?(now construction only): Yes No Application for Disposal systern 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) Relative to the application of 2A (Installer's name) And dated (Original date) Dated ay C ate With With revisions dated(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 plans and the permit on site when arty work is being &tie. 2. As the installer, I roust call for any and all.inspections. If homeowner, contractor,project manager, or any - other person not associated widi my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As fl- Le installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that req;LLwithout,completion of the items in accordance with.Title 5 and the Board of Health Remnilations nay-result in a$50.00 fixLe-beinLy levied a"inst me and/or mT-,:oLi a. Bottom of Bed--Generally, this is the first (1,t) inspection unless there is a retaining wall, which should be done first. The installer inList request die.inspection but:does not have to be present. b. Final Construction Inspection—Engineer must'.first do theii,-inspection for elevations, ties, etc. As-built of verbal OK(or e-rnail to: hc,,.tltl-idept@nottl-iandovemia.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection ffine. Installer in-List 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 (al5or 11)an siwple exremzfion)and I arnrequired to corriplete the installation of the system identified in the attached application for installation. I further understand that work.dome by others unlicensc_d_to install septic systems in North Andover Carl Constitute reasons for denial of the system andLo.regys)ca crate in thcTown of 1- North Andover,,qjgrjf figgit fines to aLl e Ats -possible. L-persons involved ar 5. As the installer,I-anderstand that must be on-site during the performance of die followingconsauction steps: a. Deten.nmation that the properelevation 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 ol'tanlc, D-Box,pipes, stone, vent,pump chamber, retaining wall and other C0,111POPents. 6. As the installer. ]' understand that farn sole1v resDonsible for the installation of thestem as per the approved I approved No instqicdgns by the home=aer�general cantrac.tor, r any oilier persons shall absolve me of this 0 iga bl Undersigned Licensed Septic Installer: (17oday's Date) E3 1161 pa A Town of North Andover HEALTH DEPARTMENT LEA I E: ") CHECK##:� o. � LOCATION: 3. H/O NAME:.._ CCC�NT"RACICF . 1 AME: .� . . , en.�e•(Check Type cif Permit car C ic� box) ❑ Animal _.s_ $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Duntpster $ ❑ Food Service. ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ -- • Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sttstems: ❑ Septic--Sail'Testing $ ❑ Septic-DesignApproval $ Septic Disposal Works Construction(DWO $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Depart $ i ❑ Other:(Indicate)µ_____. _..__. $ a1ZhAgent Initials White--Applicant Yellow-Health Pink o Treasurer