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HomeMy WebLinkAbout- Permits - 2163 TURNPIKE STREET 3/19/2019 I i _._.._ a _L lock-Lot •� Commonwealth of Massachusetts .1_08.___._C0067-_.------- * / i ;rgi • � OF Permit No BOAR HEALTH BHP_2019-0019 a, ` North Andover '�, FEE $175.00 P-1. DISPOSAL WORKS CONSTRUCTION PFERMI'I" ranted Jatnes Bgracze_-_.-._._---- Permission is hereby g - _ to(Construct) an Individual Sewage Disposal system. at No 2163 TUIiNPIK:E S f R13 - D ar 1 g w, 19 ation for Disposal Work,Construction Permit No. as shown on the applic 019 e BOARD OI'iiE;ALTII Issued On:Mar-18-2019 i I 1 Application for Septic Disposal SVste TODAY'S DATE . I ­_­­_ Construction Permit — TOUN OF $17� .00Full RepairNORTH ANDOVER, AM 01845 00-Component Important: Application is hereby made far a permit to: When filling out system* forms on the computer,use F] Repair or replace an existing on-site sewage disposal system* only the tab key I�Repair or replace an existing System component What? to move your cursor-do not use the return A. Facility Information A key. �Ulv Address or Lot# _6fyJ_Town /eGan2.-*TYPE OF S—E-P- TIC_SYSTEM*__:____ > El Pump, Gravity(choose one) *If pump sys to in, attach�ch',copy of electrical permit to app fica tio r i > E]Conventional System (pipe and stone system) > 0 Infiltrator or Blodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.) )> El Pressure Distribution S.A.S.(No D-Box) > 0 Does the system require an effluent filter? Yes Y-- No If yes,does plan specify make and model of filter? YES =(no further into. needed) NO =(installer must specify brand of filter before DWC issuance) MbRtis the- 2. Owner Information Name Address(ifdifferentfrem a ove) -dityfrown State Zip Code 6"' _Criia Fladdress Telephone Number 3. Installer Information C Z.e di AVL Name Name of Company X .2c Addy ss 11Y ro State Zip Code Telephone Number(60 Phone#if passible please) 4. Designer Information ame Name of Company -Address -di-t-yiTown -State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page I of 2 Application for Septic Disposal System l ODAY'S DK['Ei Construction Permit — TOWN OF NORTH ANDO►VER, MA U1845 $'175.75.00-Full Repair $ 00-Component PAGE Z OF 2 A. Facility Information continued.... i Residential Dwelling or[]Commercial 5. Type of Buildillq.P 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 understand that until a final Certificate of Compliance has been issued by this.Board of Health,the installed system is not approved Date -------------- Appo(,a ion A ed By. (Board of Health Representative Nme - Date Application Disapproved for the following reasons: For Office Use Only. 1. Fee Attached? Yes ` No 2. I'xoyect Maxza�Crex Oblrgatiotz Fotxrx Attached Yes � .No_—. .3 Pzztxz.__S stem? Ifso .Attach coz7y_�at'ElectxrcalPmlt Yww_ ""tea Applicant received copy of "Electdcal Inspection Notes far Septic Systems" Yes=m._ .Haxzdozzt? 4 I?evzewed appxowd lette, all papet woxlrxecezved 5. .Foundadop As-Built?(new construction only); Yes Na.----_ (San2e scale as approved plan) 6 .Floax'Plans?(new construction only): Yes .mm .,° NEB Application for Disposal System Construction Permit-Faye 2 of 2 SEPTIC SYSTEM INSTAIJ ER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the proper t: at: �r ('address()fSeptic S sicrn) For platas by n nk rsrtccr Relative to the application of g r C�"t--�A ('In;stalle s name) Arid dated 01 �����)�'Jti.„li Dated s ' yw -(FocTSc�) With revisions dated ' (I ,,is( i°ct`isecl dare; I understand the following obligations for management of this project: I. As the,installer,I am obligated to obtain all permits and Board of 1-health approved plans prior to performing any work on a site. I must have the approved plans and the_permit on site wlicn any work is 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 itern three shall be applicable. 3. As the installer,I ant required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that reclrtesting an insr)ection, without completion of the_iterr'is in accordance with Title 5 and the Board ofPeaith Re ug lations m ay result an.a...,. � _.__rr 5(J.0O fine bem levied a rarn5t me and or my compa a. Bottom of Bed—Generally, this is the first (1`� 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—Erigineer-must first do their inspection for elevations, ties, etc. As-built of verbal<:)K (or e-mail to: healthelc..hrt(ar)to�une�atnc�t A srrdowFer.ce; ) fi-orn the engineer must be submitted to the Board of I-lealth,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.Gracie— 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 (off/per Man sil,�bk excapation)and I arrl 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 stem and o,_a vc catiarr or Suspension of my license to operate in the Town of North Andover signit'icarit fines to all t-)crsons involved are also Possi} lc. 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 inspection by Board of Health staff or consultant. d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining tva11 and other components. 6. As the installer, I understand that I am solely responsible for tk installation of the system as_perk_the a. roved pbins. No instructions by.thc, homeowner.general contractor.,or-anywother persons shall absolve me of this obli.ation. I Undersigned Licensed Septic Installer: J d;k 0 L.C/L ("I`oday°s Date,) (N arse— Print 4c rile--Signed) � I f`0aprr� 6 a � Town of North Andover HEALTH DEPARTMENT ENT CHECK# �._ DATE, "��� ; H/O NAME: CONTRACTOR NAME: Type of Permit or Livens—e: (Check box) 0 Animal $ ® Body Art Establishment $--- ® Body Art Practitioner $ • Dunrpster $— ® Food Service 0 Funeral Directors $ ® Massage Establishment $ 0 Massage Practice $ -- 0 Offal(Septic)Hauler $- 0 Recreational Camp $ ❑ Sun tanning $ 0 Swimming Pool $ ® Tobacco $ El Trash/Solid Waste Hauler $_ ® Well Construction $ SEPTIC Sitsterns: © Septic-Soil Testing • Septic-Design Approval ) i� $ �i Septic Disposal Works Constru Lion(DWC) $^3 i 1 Septic Disposal Works Installers(DWI) $ Title 5 Inspector $—— Cl Title 5 Report $ © Other:(Indicate).. $—----- Wi 'ealth Agent Initials White-Applicant Ilealth Pink- Treasurer w