HomeMy WebLinkAboutDWC - Permits - 234 BRIDGES LANE 6/13/2019 i
i
i
Commomealffi of Massachusetts
--------------------------
BOARD OF HEALTH Permit No
North Andover _BHP,-2 - -52
__------------- --
I y 1.
M 9 Y
I I I ttYPY9 Y I t�� d
I
5 0 0
%U%N PERMIT
� f
l�
� a
DISPOSAL WORKS '4u�ONSTRU,!C,,�T,,I,',",,,;
D
Pb M iy h '
John Divine z
Permission i here granted
a
nsh t)an Individual Swage Disposal SySteMr.
t No 234 BRIDGES LAND
shown on the application for Disposal Works Constructlon Permit - I 152Iter4tune___- ___ _____-_____ __ _
----------------------------------
Issued M Jun-13 2 19 BOARD OF HEALTH
if
1
J
1�
J
1
i
J
J
i
4
t� M
Ap,pfiGavonfor,
TODAYS DAB
Construction Permit
$ 5 . -Full Repair
TI MA 0118
. ,Gn
_LN ORHANDOVE-, 45 $175001
rrr � � r made ri
Where �l � oast Construct new ors-site,sewage disposal system*
forms the
Repair r - l existing ors-site sewage disposal system*
computer,use I %,e A
'only
to move Your
error-do not
use the return A. I ad I In orma n
key. /,000v
le
,address o r Lot# �
wo
A/0
^o
by
City/Town
w
2.- TYPE F S C SY r
> 01 pump tq' rt sere
T ,ump system, attach copy electrical p envito applicia flon Alow � °
Dora na System (pipeand stone system) ����
)> 0 Infiltrator r 1 � a ser(Gravel-Less) copy �r c i a � � � � .
)> El Pressure Distribution S.A.S.(No D-Box)
rau e
Does the system require effluent filter? Yes -,
If s, does p a specify make and model "' 1 e , ' YES further Info. ne e l
JV (installer must specifybrand of filter befdre,DWC Issuance)
Uyntisthe ,. matls the Mudd? ,
2. Own or Information
F
e �
e na—
Name
Addre H different fro above)
0
city[rown State Zip Code
Email address Telephone Number,
:3. Installer Information
Name of Company
Name
a
rym
i State :dip Code
Telephone Number Geff Phon ifp ossibleplease)
4
Pesi rmatioll
Name of Company
Name
Address
1 ��
Telephone r(Best 4 to Reach)
Application for Disposal System Construction Permit Page I of 2
4
C%
for c Asa Systemfi
cain Se i 0-MTODAYS DKFE
Construction Permit "Womt TOW N OF
$350-00 Full Repair
AJA 018,45 $175-010
Component
NORTH ANDOVE-Z
PAGE 2 OF 2
A. Fa,Gil ity Information cone nuedA3.xM
W�
5. Tyne of I Building.,, DResidential Dwelling or Eicomm erdal
B. Agreement
The undersigned agrees ensure the Gonstruction and maititenance of the afora4escribed
VIS10
cn,,,I,,sIite sews ge dispo�sal system in, accordance with the Pro ns of Title 5 of the
Envi nin tair Co as wejj as the Local Subsurface Disposal Regulatiom for the Town,of
JVo An v n, erstaqd that until a,final Certificate ofCompliance has been issued by
0 as er
v�ta
thl, oa , o e. �h the stalled system is not approve
Date
N me 0
77:
0
Ap 10; Board'of Health Representative),
,pl
ic" Jon rov,ed BY:
Date
Application Disapproved for the following reasons:
For Office Use OnlyI; Yes t.,Oeolo�eol'/ No
FeeAthqcbed? No
2 p foject.Mqpqger ob-figa,170121Fbim A ma ch e d?
Ifso tach ctonv OfElectficRIPelmit yi�
At
App,ficafi t-te cel ved cOPY Of Yes'
4wie c tdcal]b sp,e c do-n No tes for Sep tic Systems
Handout?
4. PP P
Vic ape iwoWr-tecei'ved? "10
Re wed aj0w'dJCtte
9. Foun,dadon As-Bailt?(now construction only), S
S
(Slame scaleas Approvedplan)
0
6. Eloot Pas?,(new construction only), Y Xs
x
Application for Disposal Systern construion Per,mit-Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North dovet Ecensed installer for the cony ttucti coon for the septic system for the Ptopetty at:
10?
P/
Fox plansby
(Address of septic syste
er
(Ei
Rehafive to the applicat,ion of "lion
(Instafler's'name) And dat,ed
IV
/14
Dated
9
-4 Withrevisions dated
Croday S, a (Lalst mvised date)
I understand,tie foROWIng obliga,tions for management of thiis project:
1 Asp instaH.er I ara obEgated to obtain,all penDits and Boatd of Health approved plans vnot to
perfotmin 9 any work on a site., I must.have the xppt-oved-olans and th"2Lcrniit on site whhen anv work is
being done,
2. As, the installer,I inust cO for any and all inspections. If homeowner, contractor, Project managet, or any
0
other person not associated with my compariy schedules an inspection and the systemi's not reaidy> then
item thtee shall be applicable.
3, As the Installer)I a,,m required to have the necessary work completedprior to the applicable inspections as
indi,cated below., lundetstandthatic-questinvan ins-Dection,Withoutcoln-Oletion ofthe items m accordance
with, 'Fitle 5 and,the B,oard of Health Ree�ulafions,tea. result in, a 350.00 fine bed l g . ai�st �and�o�t
.1
MV Coln-Dan ._
a., Bottom of Bed-Generally, thisis the Est(V�inspection unless thete is a tetanai,ng wall,which
sod. be done first. The instaUer must request the m" spection,but does not have to be p-tesent.,
b. Fi-xia Construction Inapt!q i ) ties, etc.
�ionl —En&eer must Est do theit inspection, for elevations
As- ui.t of verhal OK (or e-mail to-.,healthdept@no-tdiandovej,.nia.gov) ftom the engineet must be
submitted to the Board ofHealt-h 1) after which installer calls for an,mspection tm, e. a . t be
present for t-bis inspecfion. With a puinp system, all electrical wo:rk must be teady and able to cause
pwnp to work and alai ta to Function.
c. Fm" Al Gr�ade—Installer must-tequest inspection when all grading, is complete. InstaRer does not
have to be, on-site.
4. As the installer,I undetstand that only may perfottn die,work, (otber than simple, excavalim)and I am, requi-ted
to complete the,Installation,of the system idendfied i-ta the attached application for M' stallation. I fw--ther
understand that work done by others wilicensed to i ..stall
tea s Ons foj:dem*al-of the, systems.and/or,revocation or_SUSD erasion of mv license to o.. etate in th,e Town o f
A.
Noith ArLdovet, s rnifica le.
5. As the m* stallet, lundetstand that I inust be on-site,during the,petforinance offfie following constraction
steps:
a. Deietmwatjo_n that thep-topet elevation of the excava-tion has,been feacbed.
h. Inspection of thesandand stone to he used.
c. Final.11'Ispecdop by Board ofHealth staff or consultant.
d. Ins tion of tank, D-Box,pipes, Is tone, vent,pamp chainbex, setabVog will an d oth e-t
components.6. As the installer I understand that I am sole1v for the installa 'on of the s
tl
'bv the hol-neowner,
_gqger qons shnaAn absolve
me of this, abliga6on.
Undets,igned Licensed Septic Installer: Dat,
"'Ole
10
le—
e
(Name—'Print)
w m N..
Rrelference No,,: BlIJ-21019-10,00019Ni
234 BRIDGES, LANE
Permlt 'No: BHP-201.901,52,
Departmen t
North Andover BOARD OF 11FALT 11
Account No: 10 0 10 0 1.1, 5.0 5 1 101,0 0 1
Fee Type:
Receipt Nol: REC-2019-00,0352
1, PEJ I M 0 M,a I I#0 M M Ml M M Ml M,Ml M M�140 0 M IN M 0 M I M 1�w
)WC-C iY
o niponent Repa"r 1MIT
U'll
Paid in F Oino Tim Jun 13,2 019 Paid By: *MMlMll*Nllw*ftMmlM Oml"I OMWM
Yk
o h n V
incenzo
N I #
Check No,
M I 18,390
Received By:
na om' Wolfende n
14111111"Owwwloomll 110"IN wVM,mlWl*WMl
COPY Amount- $175-0,10w.
DEPARTMENT'S
..........
............. .....