HomeMy WebLinkAbout- Permits - 1015 FOREST STREET 2/13/2019 (3) i
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Commonwealth of Massachusetts Map-Block-Lot
BOARD OF HEATH (0A r, �05 DooSs __ ...._.h , 0
Permit No
Forth Andover ,
15, q, '`' BWF 2019-0005
P.I.
,.< FEE
F.I.
$350.00
DISPOSAL. STORKS CONSTRUCTION PERMIT"
Permission is hereby granted James Kellett
to(Construct)an individual Sewage Disposal System.
at No 1015 FOREST STREET
as shown on the application for Disposal Works Construction Permit No. 131-1P-2019-00 atecl 3a y 20
Issued On: Jan-15-2019 13OAKD OF HEALTH
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• Map-Block-Lot
err��Irt� Commonwealth of Massachusetts 105 D0055
HEALTH BOARD OF HEA
• ,,- 1'ennttNp
North Andover -- --2------- -
.*1 °� C� FEE $350.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted .lames Kellett ---- ------
to(Construct)an individual Sewage Disposal System.
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at No 1015 I{ORESI' STREET .._ ... -..
as shown on the application for Disposal Works Construction Permit No. BHP-2019- ated
Issued On: Ian-15-2019 BOARD OF HEALTH
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Application for Septic Disposal System ` �' ``
„ TODAY'S DATE
Construction Permit — TOWN OF
$350.00 -Full Repair
qW NORTH ANDOVER., MA 01845 $175 00-Component
Important: Application is hereby made for a 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? r
to move your
cursor-do not
use the return A. Facility Information
key.
Address or Lot# t f_Lt f 6C) ) i ('
_----__
City/Town
'Bran 2.-*TYPE OF SEPTIC SYSTEM*:
> ❑ Pump Z Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
Y ❑ Conventional System (pipe and stone system)
> )6 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)
➢ ❑"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)
WLiatis the Make? What is dieMod('4? ...... _
2. Owner Information
..,
_
Name
Address(if different from above)
CityfTown
State � Zip Code
Email address Telephone Number
3. Installer Information
Na me
Name of Company
Address ,
r Zip Code
City/Town p- � y w., ,
,-
Telephone Number(Cell Phone#if possible please)
4. Desi
gner Information i r �
Name
u
Name of Company j
Address
r �
_City/Town State lip 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
NORTH ANDOVER MA01845 $$1 .00
00 75.00 -Full Repair
a -Component
PAGE 2OF2
A. Facility Information continued.... t
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5. Type of Buiidinq: Wesidential 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
h" Board of Health, the insalle ystem is not approved"
me Date
Applic,I pgr( By: (Board of Health Representative)
Name Date
Applicatio CDisapproved for the following reasons:
For Office Use Only:
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1. Tee Attached? Yes_ No
2. Project Manager Obligation Forrn Attaclied"? Yes No
3. Ptrrnp 5�st m? If so,Attach co r�ogMecttrcalPermit Yes_ No
-x
Applicant"ceived copy of
"Electrical Inspection Notes for-Septic Systems" Yes --
Hatldout?
p
4. Reviewed approvallettes, allpaperworkreceived? Yes- No
Missing:.
5. Fozmdatiorl As-Built?(new construction only): Yes N
(Sarre scale as appr°owed plan)
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6. Floor Parrs?(new construction only): Yes N
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Application for Disposal System Construction Permit-Page 2 of 2
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Town of North Andover
HEALTH DEPARTMENT
A`��RCFYUSCy
CHECK.#: , DATE: �°� ' of
„ .. -�
LOCATION: ���� - }
CONTRACTOR. NAME:
T e of Permit or License: (Check box)
❑ Animal
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service_1pC'-. .. —_ $
❑ Funeral Directors $
❑ Massage Establishment- $
❑ Massage Practice $
❑ Offal(Septic)Hauler $_
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool
❑ Tobacco $_
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC St stems:
❑ Septic Soil Testing $
❑ Septic--Design Approval " $
Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5Inspector $�
❑ Title 5 Report $
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❑ Other:(Indicate). $
H aX agent Initials
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White-Applicant Yellow-Health fink- Treasurer
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