HomeMy WebLinkAbout- Title V Inspection Report - 337 PLEASANT STREET 5/2/2019 (2) I
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Commonwealth of Massachusetts
BOARD O HEALTH ---------„ __.
Permit No
North Andover
BHP,-2019-0076
FEE
a'('
F.I.
'WORKS Om""ONSTRUCTION
UISPOSAL
PERMIT
Permission
m,
her granted Todd B
ateson
t (construct)an Individual sewage DIspoisal System.
1
at No
33-7 P STRE ------------- ___--__as
1
shown on the application forDispoisal Works nst t n Pennit No. B 9-0076 .w
�p
Apr-
BOARD -------
0 JA
J
i
i
, ar Application for Septic Disposai
TES DATE
Construction Pet - TOWN OF
$350.00 Pule Repair
NORTH ANDOVER31 5. Component
I cation is hereby,mad'e for a,Permitto:
When filling out Construct a newon-site sewage disposal al system*
forms, the
computer,use Ej Repair or replace an existing on-site sewage disposal system*
only the tab k,to move yourey x ,.
allr+ r replace n existing systemcomponent—What? b �:�
dk(,he,I 1ex—
u r sor-do not use the return ' ci l. y Information
J
Address or Lot
tab
Cit lT wn .)vzizz
Pump Gravity(choose ore),
*ff pu� gym, attach copy ll permit application'
)> C arm n i rm i System (' fie and,stone system)
El Infiltrator or Blodliffuser(Gravel-Less)(Attach copy of your certification to instead this type of system.)
Pressure istrl a rm S.A.S. i -Box)
Ej Pressure Dosed(D-Box Present)S.Q.S.
0 Does the system require are effluent filter? Yes No
If i
yes,does plan specify make and model of Mter? YES �(no further info. needed)
i
(installer must specify brand of filter before DWC issuance)
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Who t is die Makes WhatIs the
2 Owner Information
Name
M. 1
Address if different from above) 14-5
Cit /To,wn State Zip Code
Evil address r
I Installer lInformation
Name Name of'%=,S0N'ENTERPFjjsMjNG,
Address
MAI 0
—M-OMER
Cityffown Stag wl
., P
Telephone Number(Ceff Phone,#if possibleplease)
14. Designer Information
Name ame osornpany
Address
�t^ rr State Code
Telephone Number Fast#to Reach)
Application for Disposal System Construction Permit Page 1 of 2
B
APP itoration TIor Septic Disp moo Sys
0 1 Item
a '
TODAYS DATE
Construction Permit — TOWN OF
o
V
$3501.00-Falb Repair
NORTH AN,DOVEI,R,,----AIA 01845, $1,75-00 Component
PAGE 2 OF 2
k FacilityInformation c°continued....
5. Type of Building: [DA�esidentlal Dwelling or[IGommercial
B, Agreement,
The undersigned agrees to ensure the construction and maintenance of theafore-descilbed
on-site sewage disposal system in accordance with the provisions offitte 5 of the,
Environmental Cede, as well as the Local Su surface Disposal Regulations for the Town of
North Andover. l understand that until a finalCertificate of Compliance has been issued by
thi's Board of M l l the installed system is not,approved
o
Name Date
llc l , r : oars'of HeelRepresentative)
I me Date
,Application Dllsappr'oved for the i ll wtin reasons:,
i
-------
For Office Use 0�
Fee attached? Yes No
2. Project Manager ObEgation Form Attached? Yes No
3. Pump S�� � " ""s ach c f c ic�P ,Yes Now.
Applicant received copy of
'WiectricaTInspection Notes for Septic Sy steins" Yes No
n
approval letter
all paperwork e Yes No
Foundation As-Built?(new construction only): YS N
(Same scale as a p n an
6 Floor Plans, (new construction only). Yes No
t
1
Application for,Disposal,System Construction PerTnit Page
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SEPTIC Wa INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the'NorthAndover licensed installer for the tru ti or the septic system for the ro r .t:
3.
�
For plans,by
Relative to the ti :n /1.1/
)rtgfi'', .',,te
Dated
'With,revisions dated
understand the folio * obligations for management of this project:
1. As the installer. I am. l ligated to o tai all p i `t anidBoardof Health.appravedplansprio-t to k is
: o any work n site. I mast have, r
being dore.
2. As the Installer,, I must call for any and all inspections. If hom, eowner,contractor,proIject manager,or any
other r ,not associated with
my co�pany schedulesare 'inspection and thesystem is not ready, then
item three hall be app gable.
ry�t� p p � pp
Asthe i.�7i t �er, required.t . the�, l completed tothepeetr :
indicated,below.w. I understand that re e ti-n n ins ectui Without eon leti the items in accorda
Wd or
ith"fide 5 and,to Board f,Health, e l tion result i .a 50.00 e � � Est��� ���
jny .e tr� n-..
a„ Bottom of B —Generally,this is the first � inspection unless there is a,retaining wall,which,
should be done fist. 1"heinstaller must request the inspection but doe ot have to be present.
b. Final Construction Ins a ti —Engin,CIII Nest Est do their inspection for elevations,ties, etc.
nust
(Or e-rnafl to: rthatidcne c
e submitted to the Board of Health,ate which installer ems for an inspectiontime. Installer must
be presentforthis inspection. With a put-npstem,all electricalwork,must be ready and,able to
cause pump to work and alarm to function.
c. Final G Itsr must request qt p et o when all grading is co plete. Installer does not
,
have to be on-site.
. As the .installer,11 understand that only I may perform the work (office Mail sitilplexc i i and I am required
to Complete the installation of the stets.ident,11fied i .the attached application for installation,. T ffirther
understand that work done ,dover can eonstit t+
reasons for denial of t . ,S o erate in the To,wn of
North e, si,anificant fines to,all er n involvedare also it ie.
* the installer .� understand that must e on-site ring the per rmane � ll ���construction
to
a. Determination that the proper f the excavation b been e � .
Inspection of the sand and stone to be used.
. Final inspection y hoard of Health staconsultant.
d. Installation nk stone vent,pump' ba n ng wandher
components.
6. As the installer I understand that I am,solelv r -on i le for the in, tallati n. of tie Ater e t
he
: e plans, N instructions b the t.e � � e t��aet �� t�� ll e
e ofthis obhgattion.
Undersigned U
censedSeptic Installer :
,
m�
d
i
JUNO 04�
* o wn f" tAndover
C" a M
HEALTH DEPARTMENT
ACKV
CHECK.
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LOCATION" I� „�(tA
IM Ihuuo 9'� w''vfW 3wf �0 mi N�Tr�^'91 Nk'�Y� 'Nv���,an^� VFd�'N �GmIDI�' utid�
H/O NAME:
+'�SMrl(rJ�d
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CONTRACTORNAME-p 11"i 0 �"w��"' c elf,
Tof erm License,: (Check box)
Animal
Body.Art en
Body.Art ' a -i
i
umps
Food Service y
Funera ID trecto rs
Massage Establishment
13 Massage practice
Offal(,Septic)Hauler
Recreational Cam
Sun tanning
Swag Pool
13 TrashlSolid Waste Hauler
Well Coil's
SEPITIC SO
Septic Soil Testingm
� ,�tl�
0 gyp° sil Approval
Septic Disposal Works,Cottstniction
Septic Disposal Works,Installers
0 Title
Title 5 Repot
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eil'bp Agent Initials_
White-Appucant Yellow-H'ealth Pink- Treasurer