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Home My WebLink About- Permits - 50 FARNUM STREET 11/21/2018 (I 1 Commonwealth of Massachusetts Map-Block-Lot 107A0087 BOARD OF HEALTH No Permit-------- North Andover ----BHP 18 pg21 FEE $350.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter Breen to(Construct)an Individual Sewage Disposal.System. at No 50 FARNUM S 'REET as shown on the application for Disposal Works Construction Permit No B-111P-201 r, atecl ve 018 _. - ----.-.... Issued On:Nov-21-2018 BOARD OF HEALTH Application for Septic Disposal System � Construction Permit -- TOWN OF TC7DAY'S DATE $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component Important: Application is hereby made fora permit to: When filling out VS Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* e only the tab key ❑ Repair or replace an existing system component-What?___,.._ to move your -� cursor-do not use the return A. FaGility Informat ion it key. '54°m --- 54 "t : Address o �.��: f7 r Lot# 1 r City/Town 2.-*TYPE OF SEPTIC SYSTEM*: - -- ➢ ❑ Pump Gravity(choose one) ***If pump system, a S copy of electrical permit to application*** 9 ❑ Conventional System (pipe and stone system) ➢ ® 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) ._.m.--- 3 - ❑-Pressure%�osEd°(D=Bust.Presettt):S:A:S. ,.-_-..-�... - Y ❑ 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) W45at is the Make? What is the Model? 2. Owner Information _._.... Name Addr gas if diff feat-from above City/Town Stat Zip Code Email address Telephone Number 3. Installer Information Name �- Name of Company 7 - .. Addre s CitylTown State Zip Code 'r , 2 - Telephone Number(Cell Phone#if possible please) . r Information .. 4. Designer,�" aw.. q � Name of Company Name ^� _ e"7 0 a F e .. .... WAddd s Z-1 ._ City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 1'12c Application for Septic Disposal System " Construction Permit — TOWN OF FC)DAY'S DATE $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component PAGE 2OF2 A. Facility Information continued.... j 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 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 Jme Date ationApprovecy: oars f,.Health Representative) N me Date Application Disapproved for the following reasons: For Office Use gnI 1. Fee Attached? Yes IV0----------- 2. Pro'eet.M. axza -et Ohlz atz«xz Form Attac&ed? Yes No _. 3. Puma S sfr ? If so,Attach q_gPY ofEle-ctricalPe.gn t Yes_.__ No Applicant tecelved copy of "Electrtcallbspection Notes for Selido Systems" Yes._.— N0_..___ Ilatldout? 4. Revzewedapptovalletter, affpapez-wodcreceivecl? Yes No_-----, Missing: -- 5. Foundatro_,As-Bvt7t?(new construction only): Yes Nok (SAMe scale as approved plan) G. Floo.I.Platls? new construction only: Yes No� ( ) Application for Disposal System Construction Permit•Page 2 of 2 114P. SEPTIC SYSTEM INSTALLER.PROJECT MANAGEMENT OBLIGATIO*�/ ' As the North Andover licensed installer for the construction for the septic system for the props �k)/?p, 0Z 14& (Address of septic system) For plans by (Engineer) Relative to the application of (installer's name) And dated 0C F t/ ` 4' / ��y (Original date) Dated / ( (Yoday's date) With revisions dated /I'OL� d� (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 perfor.niing any work on site. I must have....the_qp roved plans and the permit on site when any work is _ .. ..... p heing done. 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 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 'p indicated below. I understand that requesting an inspection,without cotnplef ton of die items in accordance with Tide 5 and the Board of Healdi Regulations-in U_' result in a $50.66-'—fine being levied against me and/car my c DMPAiiy. a. Bottom of Bed—Generally, this is the first(V inspection unless there is a retaining wall,which should be clone first. The installer, must request the inspection but does not have to be present. b. Final Construction Inspection---Engiticer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail.to: healdidcl-)L@northandovetma.gov) from, the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer rnustbe present for this inspection. With a pump system, all electrical work must be ready arid able to cause pump to work and alarm to function. c. Final Grade—Installer must request itispecdon 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 ii;vaplo excavation)and I am required to complete the installation of the system,identified iti,the attached application for installation. I further understand that work,cloqg�_both�ets unlicensed to_install�scptic�ssteinqiu.North Andover can'constitute reasons for denial of the s�e.tn andf or, revocation or suspension of my license to overate in the Town of North Andovct'jj�ficaat fines to all t)ersons involved are also possible. 5. As the installer, I understand that in-List be on-site during the performance of the following construction steps: ,q. Deteimina don that the prope_r elevation o.f the exca va don has been Leached. b. Inspection ol*tbe sand and stone to be used. c. Hnal inspection by Bow-d offlealth staffor consultant. d, lostaRadop of tank, D-Box,pipes, stone, vent,purnp cliamber,xetakzipg-u-dfland otbat COMPO-nef7ts, 6. As the installer understand that I am solely reapQ nsi�l.�,-for-d-he installation of the systern as per the J appLaved pLas—g . No instructions the q-Ttlet,genetal contractor_ -!2y t— _kQMq or any pther-pe-tsons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) Ai- 4r� �Na_m 1:.W—n--t) (Name—SigH6 r pt"µonrH qk a nxi « . Town of North Andover PLEA1,TH D EPAIITMENT 1s'4"ACHUSES CHECK #: c � DATE: LOCATION _ fl NAME: �. I I ,W CONTRACTOR NAME: _ , /CS'µ"" Tvve of Permit or License:(Check box) 0 Animal $ ❑ Body Art Establishment $ __ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Set-vice- $— ❑ Funeral Directors $_ ❑ Massage Establishment $ ❑ Massage Practice $� _ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ � ❑ Swimming Pool ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC S�teins: ❑ Septic a Soil.Testing $ ❑ Septic Design Approval $ Septic Disposal Works Coustruction(DWC) ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ — ❑ Title 5 Report $ ❑ Other:(Indicate)„_,...._..,.._ �. _ $ _ Malth Agent Initial White m Applicant Yellow-Health .pink Treasurer