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Home My WebLink About- Permits - 246 CANDLESTICK ROAD 11/26/2018 ............... ...............- . ...............---............. .......... -......................... .................... ---—----------- ---,---- --- Commonwealth of Massachusetts Map-Block-Lot 106A201 BOARD OF HEALTH Pennit Na North Andover BH-P-2 1 0 1 18--0823 P.I. FEE F.I. $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted R-obert.-Herrick to(Construct)an Individual Sewage Disposal System. at No 246 CANDLESTICK ROAD as shown on the application for Disposal Works Construction Permit No. BHP-20184-0 ;aked ven er 018 Issued On:Nov-26-2018 BOAKD OF HEALTH ....................---- Application for Septic Disposal System, TODAYS DATE Construction Permit - TOWN OF $350.00-Full Repair NORTH DOVER, MA 01845 $175.00-Component Important: Application is hereby made for a permit to: When filling out F1 Construct a new on-site sewage disposal system* forms on the computer,use El Repair or replace an existing on-site sewage disposal system* only the tab key to move your Repair or replace an existing system component-What? cursor-do not use the return A. Facility Information key. '7 t�"/,, Address or Lot# City/Town 2.-*TYPE OF SEPTIC SYSTEM > El Pump ER Gravity(choose one) ***If pump system, 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.) > ❑ Pressure Distribution S.A.S.(No D-Box) A-,.S.. >---EI-Pre-ssure-Dos'ed,-(D-rBox,Present)-, > n 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) Wh2 t_iS the Make? what is the Mode p 2. Owner Information Name Address(if differen from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address -City/Town State Tip—Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component PAGE 2 OF 2 A. Facility Information continued ... 5. Type ofBuilding: R'Residential Dwelling or FICornmercial 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 -------------- p Ica pp Approved"Byi 031a of H�alth Representative) I Name Date c:::-_ I J Application Disapproved for the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Sys ? If so,Attach cop Jectrical Peimit Yes y ofE App,Ucan t xeceived copy of "Electrical Inspection Notes fox Septic Systems" Yes ,Na Ma n.do u t? 4. Rei4ewedapprovallettet, all papatwoxk-received? Yes Missirxg. 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6 Floor Plans?(now 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: (Address of septic system) For plans by (Engineer) Relative to the application of (Installer's name) And dated (Original date) Dated Z''IK (1-oday's date) 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 approved1f plans '12110 to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As & *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. 1 As the-installer, I am required to have the necessary work completed prior to the applicable *inspections as indicated below. I understand that requesting an inspection,without completion of items in accordance with Tide 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company a. Bottom of Bed—Generally, this is the first (V 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 Inspection—Engineer must first do their inspection for elevations, des, etc. As-built of verbal OK (or e-mail to: healthdept@no.tthandove-tina.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 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 (other than simple excavation)and I am required. to complete the installation of the system identified in the attached application for installation. I further understand that work done by others -unlicensed to install septic systems in North Andover can.constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached b. Inspection of the sand and stone to be used c. Final inspect-ion by Board of Health staff or consultant, d Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as oct the approved plans No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obli gation. Undersigned Licensed Septic Installer: e-, (Today's Date) (Name—Print) (Name— igned) Town of North Andover HEALTH DEPARTMENT 4 CHECK#: 9 DATE: LOCATION: ........................H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) • Animal • Body Art Establishment • Body Art Practitioner 0 Dumpster • Food Service $ • Funeral Directors $- • Massage Establishment n Massage Practice 0 Offal(Septic)Hauler 0 Recreational Camp 0 Sun tanning • Swimming Pool • Tobacco • Trash/Solid Waste Hauler $ • Well Construction $ SEPTIC 5ysterns: • Septic-Soil Testing $ ti • Septic-Design Approval $ Septic Disposal Works Construction(DW0 EJ Septic Disposal Works Installers(DM) 0 Title 5 Inspector IJ Title 5 Report 0 Other. (Indicate)-- $ ........ Hea th Agent Initiah White-Applicant Yellow-Health Pink-Treasurer 1