HomeMy WebLinkAbout- Permits - 338 ABBOTT STREET 4/5/2019 Application for Septic Disposal System TODAY'S DATEw.
Construction Permit - TOWNOF
$350.00-Full Repair
NORTH A:NDOVER., NU 41845 $175 p0-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
to move your ®Repair or replace an existing system component--What?
cursor-do not
use the return A. Facility Information ,� �
key. ry'r„fiyarIk,lr„
Address or Lot#CityfFown
— -- r �-- -
2.-*TYPE OF SEPTIC SYSTEM*:� �
> ❑ Pump Eg,,Vrivity(choose one)
* 11'pump sy m, attach copy of electrical permit to application***
onventional 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)
> ❑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)
What is the Mike? What is the Model?
2. Owner Information
M
Name - _ � _ - -----
Address(if different from above)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
Name ""` Name ofSAMON�
ENTERPRISES9 ! -
Address
City/Town State Zip Code
v
Telephone Number(Cell Phone#/f possible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to!teach)
Application for disposal System Construction Permit•Page 1 of 2
Application for Septic Disposal System T(7DAY'S DATE
Construction Permit '- TOWN OF
NORTH ANDOVER, N U 0184 $ 7 - Repair
� $15.00 5.aa-Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: esidential 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. l understand that until a final Certificate of Compliance has been issued by
this Board of�Hpal , the installed system is not approved.
Name Date
Al'W do p roved By: (Board of Health Representative)
N " e Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached. Yes I/ No
2. .Project Manager ObEgadon Form Attached. Yes ', Noi
3 Pump System? Ifso,Attach!gWy ofElectrcal Permit Yes No
Applicant received copy of
`WlectdcalInspection Notes for Septic Systems" Yes No
Handout?
rovalletter, all a erwork received? Yes_"""" " " "
4. Rev%wed app p p No
Missing..
9 Foundation AsBuilt?(new construction only). Yes
(Same scale as approved plan)
d. Floor Plans?(new construction only). Yes.".".. .""""..""........_.......""w.." "".".......
a.............
...
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:
(Adckes""of sep6c S(!stcnl) For plans by
(
Relative to the application of And dated
1-mr1c)hxstalk'��"
Dated
With revisions dated
daw')
I understand the following obligations for management of this project:
t As the installer,I am obligated to obtain all permits and Board of Health approved plans PLI:jor 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 requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Healthh-kegubtions may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally, this is the first (l') inspection unless there is a retaining wall,which
should be (lone 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, ties, etc.
As-built of verbal OK (Or e-mail, to: hc,.ild con) from the engineer must
- � .1�_� V1. . " ! au- _�
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 1.may perform the work (olber than sim 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 Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the .fown 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 inspection 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 12er the.
AppiLove(tp ans. No instructions by the homeownerget eral contractor.or anv other en ons shall absolve
_ — b
me of this Abligation.
Undersigned Licensed Septic Installer:
( 77ne - Innt)
Town of North Andover
HEALTH DEPARTMENT
7
CHECK DATE: , V,
LOCATION: 3,38
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
0 Massage Establishment $
0 Massage Practice
• Offal(Septic)Hauler $
• Recreational Camp
• Suit tanning
• Swimming Pool
0 Tobacco
0 Trash/Solid'WTaste Haider $
0 Well Constniction
SEP77C Systems.
• Septic-Soil Testing $
• Septic-Desig-ii Approval $
Septic Disposal Works Construction(DIVC) $
0 Septic Disposal Works Instedlers(DWI) $
0 Title 5 Inspector $
0 Title 5 Report
0 Other. (Indicate).--,..-- $
HeWth,Agent Initialsi
11ILite-Applicant Yellow-health Pink- Treasurer