HomeMy WebLinkAbout- Permits - 65 SUGARCANE LANE 11/27/2018 I,
Commonwealth of Massachusetts Map-Block-Lot
106 A0240
BOARD OF HEALTH
Permit Na
North Andover _BFfiP-2018 a4as
P.I. ....------. FEE
F.I. $175.00
DISPOSAL K ST UCTIPERMIT
Permission is hereby granted John L. DiVincenzo
to(Construct)an Individual Sewage Disposal System.
at No 65 SUGARCANE?LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2018-04 ate, ern r I 18
------ -------- --- --- -- -
Issued On:Nov-13 2018 BOARD OF HEALTH
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Application for Septic Disposal System
TODAYS DATE
Construction Permit - TOWN OF
$350.00-Full Repair
NORTH ANDOVER MA 01845 $175.00-Component
Important: Application is herebyn4je for a permit to:
When filling outJ Construct a now on-site sewage disposal system*
forms on the
computer,use pair or replace an existing on-site sewage disposal system*
only the tab key
to move your VRepair or replace an existing system component—What? At ./y,
cursor-do not
use the return A. Facility Information
key.
Address or Lot
CitylTown
2.--TYPE OF SEPTIC SYSTEM*:
> El Pump ff Gravity(choose one) OF Nogj+i AKYV�
I L IZ'
***If pump system, attach copy of electrical permit to application'
> [J-6o_nventionaf System (pipe and stone systom)
> ❑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)
7
> 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)
What is the Make? "atis the Model?_.._. __-__.-----
2. Owner Information
Name
Address(if different from a9we)
City/Town State Zip Code
-TelEmail address
hone Numper,
3. Installer Information
0-n Or Y
Name Name of Company
----------
Address
City/Town State Zip Code
7
Telep Piono�_Z_,bar(Cell Phone#itpossible please)
4. Designer Information
-Name of Compa_n_y __,__
Address
--------
State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal Systern Construction Permit-Page 1 of 2
I I- A
' Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
NORTH ANDOVER, IVIA 01845 $7500 COMRepair
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: esidential Dwelling or❑Commercial 1
I
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
Enviro mental Code, as off as the Local Subsurface Disposal Regulations for the Town of
North do!fH
de tand that until a final Certificate of Compliance has been issued by
this o rd he installed system is not approved.
me Date
ap' ation Approved By: o Aof,Health Representative)
�lam&
D --
Application Disapproved for the following reasons:
For Office Use pnly:
1 Free Attached? Yes 1J No _
2. l'tayect Manager Obhgadon Totin Attached? Yes No
3. Pzznzp System? If so,Attach ropyofElectticall'exzx�it Yes No—.
Appllcant,received copy of
"E'IectdcalInspectlon Notes foi Septic Systems" Yes No
Pan doUt?
4 _Reviewedappfovallettet, allpapet•wotictccerved? Yes No
Missing.•
5. Foundation As-•Bolt?(new construction only): Yes No
(Same scale as approved plan)
6. Hoot Plans?(new construction only): Yes No
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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:
r.., ,"et V` t'e
(Address of septic stem) For plans by _--
_ (Engineer)
Relative to the application of
(installer's name) 1`,nd dated f
rsgrna ate
Dated4&-3
o aate�— With xevasians dated _
(Last revised date)
1 -umderstand 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 any work is
being.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
indicated below. I:-_understand that requestirl an n ins pectianx_witlaut catnpletiqn of the items ancccrdance
with Title 5 and the Board of Heaalth.R.egYulations may,xesuult iii a 50.00 fine being levied agginst nic and/or
my company;
a. Bottom of Bed--- Generally, this is the first (15)inspection unless there is a retaining wall,which.
should be done first. The installer must recluest 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: healthdept@northarld(3ver:ma.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 s v)ple 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 Arlc over can constitute
reasons for denial of the system and/or revocation or susperlsioti of my licenst tc operate in the Towti of
North Andover,si�paificant fines to all persons involved are also possible.
5. As the installer:,I understand that I tnust be on-site during the performance of the following construction
steps:
a. Dete,t7ninad&tz that the proper elevation of the excavation has been reached
b. Inspection of the sand and stone to be used.
c. Knal inspection by Board ofHealth staff or consultant.
d. Installation oftanlc, D-Box,pipes, stone, vent,pump chamber, xetaAVhg wall and other
co zponetxts.
6. .As the installer,I understand that I am solely responsible for the installation of the system,as_per the
a a:ov_c c plans. No instructions by the homeo-wraet�general cortiractor, ar any other_I.rersans shall absolve
me of this cjAftadon.
TJndersigxlecl Licensed Septic Installer: achy'• Date)
tYle— t ame--t.lgne i —._.
0 �� «
Town of forth Andover
CHECK #;LL ' L DATE: (V1,
LOCATION: t ,
H/O NAME;
CONTRACTOR NAME:
q
Type of Permit or License (Check box)
❑ Animal
❑ Body Art establishment $
❑ Body Art Practitioner
❑ Dumpster �
❑ Food Service-Type:
❑ Funeral Directors
❑ Massage Establishment
❑ Massage Practice
❑ Offal(Septic)Hauler
❑ Recreational Camp
❑ Sun tanning
❑ Swimming Pool
❑ Tobacco
❑ Tras/VSolid Waste Hauler
Well Construction
SEPTIC Si stems:
❑ Septic-Soil Testing
❑ Septic-Desigio Approval
Septic Disposal Works Construction(Dwc) $
❑ Septic Disposal Works Installers(DWI) $ _
❑ Title 5Iuspector
❑ Title 5 Report
❑ Other. (Indicate)
Htralth.Agent Initial
White--.Applicant Yellow-Health Pink-Treasurer