Loading...
HomeMy WebLinkAbout- Permits - 404 SUMMER STREET 1/24/2019 (3) 1 Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALTH PennitNo North Andover BHA-2018 Oz73 PFF $350.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John C;hotigris--- to(Construct)an Individual Sewage Disposal System. at No 404 SUMMER STREET as shown on the application for Disposal Works Construction Permit No. BI-IP-2018-0 Dated 11 zo-` te er 018 -... -------- Issued On. Sep-17-2018 BOXRD OF HEALTH i Application for Septic Disposal System A / Construction Permit ^- TO" OF fOD 'S DATE $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component Important: Application is hereby made fora permit to: When filling out Construct a new on-site sewage disposal system* forms on the computer„use © Repair or replace an existing on-site sewage disposal system* only the tab key (] Repair or replace an existing system component—What? to move your cursor-do not use the return A. F Cility Information key. Address or Lot# _ City/Town 2.-*TYPE OF SEPTIC SYSTEM*: u El Gravity(choose one) ***If pump sy em, attach copy of electrical permit to application*** ➢ U,Conventional System (pipe and stone system) > ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system,) p IJ Pres re Distribution S.A.S.(No D-Box) .... . .P ssure�Dosed-(DuBox Present)S:A:S. _---•— — > oes the system require an effluent filter? Yes v 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 tllalte? _e,__,_m.Mbatis the Model?____ 2. Owner Information ., des(iKabove}Ad dD m La-LC o it frown State Zip Code E— 1, dress Telephone Number - 3. Installer Information _("I� � ._ e_... ._., Name of Com an. ._ _ &. Name p' Y J�Hds Im, 's And,—&a s arc City 'own State Zlp Code 8 t#c Telephone Number(Cell Phone#if possible please) 4. Designer information me Name of Company i � M_------- - ./ - _z_�.Cit / wn State, Zip Codo Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Application for Septic Disposal System Construction Permit — TOWN OF TODA S DATE $350.00-Full Repair NORTH ANDOVER, MA 01845 $1 75.00-Component PAGE 2 OF 2 _-- A. Facility Informatioa 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 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: 1 nderst � a a final Certificate of Compliance has been issued by fir' oard of H th installed system is not approved - Date Appli irAo : (Board of Health Representati/v�ee)NameDateApplicat' d for the following reasons: For Office Use Only: L .Fee Attached? yes c.% No toyectM n get� 2, l' a a atioti Forrn Attached? ye's-_� No Oh-i g 3. Pxrxxz Syste.gj? Ifso,Attach copy rrfElecttxc a 1'eimit yes-- No Applicant.teceived copy of".Electdcallnspectioxr Notes for Septic Systems" yes No.K Handout? +-' 4. .Rerrzetyedapptoyallettet, ailpapet�cvoskr�ecezved? Yes No_ ._v missing: - ------ 5. Foundation As-,Bzrrlt?(new construction only): Yes No (Same scale as appl'ovedplan) G. Floot•Plans?(new construction only): Yes No ._._ Application for Disposal system Construction Permit-Page 2 of SEPTIC: SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the forth Andover licensed installer for the construction for the septic system for the property at: W) V , F (address of septic;system) or Mans by (Engineer) Relative to the application of —— gristallees name) and dated ✓" V do IR �Onginai aarej Dated - - :"crcTayFs elate 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 pernxits and Board of health approved plans for to performing any work on a site. I must have the approved plans and the permit otl.site when any work is heigg drone. 2. As the installer,I must call for any and.all inspections. If homeowner, contracta:t,project manager, or any other person not associated with my company schedules an inspection and the system is riot 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 requesting an iaast�ec tictl without completion of the items in accordance with Title 5 and the Board of IIe alth.Re lug ations taxay,result ux a 50.00_fine being leviedagainst me and/or nx cy an�t��ny,, a. Bottom of Bed.---Generally, this is the first (1")inspection unless there is a retaining wall,which should be done first. The installer:mast request 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 OIL (or e-mail to: healtlxdept@noa:thandoverma.gcav) from the engineer must be submitted to the Board of Health, after which installer calls for in inspection tinxe. 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 (otherfhan,rivaple exraw ion)and I am requ red to complete the installation of the system identified in the attached application for installation. I fitrdict understand that work done b others thers unlicensed to install swt�c s sty enis i:tx Nortlx Azxdover can �c>nst tiate reasons for deniat of the system and/-or revocation or suspension of:my license to operate_ira the'Town of North Andovea:,_signtficant fines tc,> all persons invalv:cl aie also possible. `'>. As the installer, I understand that I must be on--site duriaxg the performance of the: following construction steps: a. Determination that the pt•oper•elevation of the excavation has beet reached. b. Inspection of the sand and stone to he used c. Final inspection by,Boatd of Healib staff or consultant. d Installation of tanlr,D-Box,pipes, stone, vent,piunp chamber, retainbig wall and other components. 6. As the installer.I understand that I am solelyresponsible for the_ristallation of the System as t)er the: approved plans. Na itxstxrxctians bythe hoarxeawner, __exet:al__contsactc7r, off:.any other persotas shall absolve me of this obligation. Undersigned Licensed Septic Installer:. (Taday's Date) J C (Name— 'rant acne_ tgtze ppNTN Town of North Andover HEALTH DEPARTMENT CHECK 4: DATE: 9 'A(V8 LOCATION: H/O NAME: CONTRACTOR NAME:1� Type of Permit or License:(Check box) 0 Animal • Body Art Establishment • Body Art Practitioner • Dumpster 0 Food Service 0 Funeral Directors * Massage Establishment * Massage Practice ci offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool 0 Tobacco [3 Trash/Solid Waste Hauler 0 Well Construction SEPTIC jyst_ellfs: • Septic-Soil Testing • Septic-Desigii Approval Septic Disposal Works Construction(DWO 3 Septic Disposal Works Installers(DWI) [J Title 5 Inspector 0 Title 5 Report 0 Other. (1ndicate),__,,____ He "ttl4gent Initia I , White-Applicant yg_kjoLjL-health 1_3ink-Treasurer �,,