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Home My WebLink About- Permits - 350 SHARPNERS POND ROAD 11/5/2018 Commonwealth of Massachusetts Map-Block-Lot r,l�flll�!rr(,'raii;'. 090 80051 BOARD OF HEALTH - Permit Na 81 North Andover BHP 2-------------- P.I. FEE, F.I. ----- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Jobn DiVincenzca to(Construct)an Individual Sewage Disposal System. at No 350 S -IARPNERS POND ROAD ------------------------------ as shown on the application for Disposal Works Construction Permit No BHP 2018 ted vet 018 .- ---------- -- ----- Issued On:Nov-05-2018 BOARD OF HEALTH I I Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF $350.00-Full Repair NORTH ANDOVER, MA 01845 $1 75.00-Component Important: AjjjEjjjEE hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* RECEIVED forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* " r only the tab key R©pair or replace an existing system component—What? ,'� �iov o to move your �� cursor-do not TOWN C NORTH ANDOV ER use the return A. Facility Informatl n IjEAC F1€ VARTMENT key. w ( J Address or Lot# ALI City/Town 2.-*TYPE OF SEP��I�SYSTEM > El Pump ©'gravity(choose one) ***If pump syjem, 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,) Y El Pressure Distribution S.A.S.(No D-Box) _ y M-Pressure Dosed(D-Box Present)S.A.S. _ ➢ ❑ 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) Mat is Me Make? W1iat is die ModeLa--- 2. Own ejr Inf ormation Name t) C _ Address(if different from a ove� ..... City/Town -- State `Lip Code Email address 'Telephone Number 3. Installer Information Name o -Nam e f Company Address y ip Code e.Git I Town Sta# 1? Telephone Number(Cell Phone#if possible please) 4. Designer Information — _.. _-_a.. _...... ... ._ -..__y ___....... Name Name of Compan Address city/town State Zip Code Telephone Number(Best#to Reach) Application for Disposal Systern Construction Permit•Page 1 of 2 i D Application for Septic Disposal System Construction Permit -- TOWN OF TOd]AY°s DATE $350.00-Full Repair NORTH ANDOVER, MA 01845 $75.00-Component PAGE 2 OF Z A. Facility Information continued. 5. Type of Building: ❑Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal s tem in accordance with the provisions of Title 5 of the rEnvirgna de, a ell as the Local Subsurface Disposal Regulations for the Town of r 1 un rstand that until a final Certificate of Compliance has been issued by e !t , the installed system is not approved. Date Applic tl" pprgv (Boa d of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes Nv.._____.. 21. PiajectMat2ager Obligatiots Fotrn Attached? Yes_--- No 3. Putnp S stetn? 1fso,Attach ca v ofl3lectr�icall'etsnit Yes _ No Applicatatxeceived copy of ".Electricallnspectivti Notes for Septic Systems" Yes No 1landorrt? 4. Reviewed approvallettes, allpapercvotkreceived? Yes No Missing. .5. Foutrdatiotr As-Bzrilt?(new construction only): Yes No (Same scale as approved plan) G. Floor Plans?(new construction only): Yes____ No I Application for Disposal System Construction Permit•Page 2 of 2 Ir f • Town of North Andover HEALTH DEPARTMENT CHECK#: DATE: LOCATION: 3,' 41 H/O NAME: 27C CONTRACTOR NAME: Type of Permit or eicense:`(Check box) • Animal $ • Body Art Establishment $ • Body Art Practitioner $ 0 Dumpster $ 0 Food Service-Type: $ 0 Funeral Directors $- 0 Massage Establishment $ 0 Massage Practice $ 0 Offal(Septic)Hauler $ 0 Recreational Camp $ 0 Sun tanning $ • Swimming Pool $ • Tobacco $ • Trash/Solid Waste Hauler $ • Well Construction $ SEPTIC Systems: 0 Septic-Soil Testing $ 0 Septic-Design Approval $ Septic Disposal Works Construction(DW0 $ ❑ Septic Disposal Works Installers(DWI) $ El Title 5 Inspector $ 0 Title 5 Report $ 13 Other. (Indicate) $ H alth,Agent Initials �ite®Applicant Yellow-Health Pink- Treasurer ...........