HomeMy WebLinkAboutDWC - Septic Permit - Permits - 137 FOREST STREET 7/22/2019 Common�weIalth f s h efts a�� " r
A BOARD OF HEALTH Permit N'(")
Narth Andover -2 9- 11 2
FEE
E
$350 1
DISPOSAL WORKS, CONSTRUCTION PERMIT
Permission is hereb,r granted Peter Brcleti,
to(Construct)an iv i s Sewage D k�fl SysterTi,.
as iowii on(ire ap licati ti for Disposal Works(',,,o'l tr .i n Peruiit No. ,019-0172f
^
i
I'
Idi 90
7
Pplicavoil for Septic, Disposal System
IODAYS DATE
constructioln Permit — TOWN OF
911W $3,50.00-FUll Repair
N OWf I-..........IANDOVE`� R- MA 01845, $175.00-Co,rnponent
..........................
I v -n
Irnpiortant,: AMI'"cation,is 1-ici ;h n adefor a-ppm1it to:
When filling()Llt. a new oar site sewac posial sySteM"'
f-C ge dis
Repair or replace ari clxtsl'mg on-site sewage dispios,al system*
fonns oin ttiel
cDni,plul,er,,ul!'J'ze M
only,t ie tab,leay 61
�piair or reply ,n existing systern c-on't ponent Whaf?
1,o i"nove,your
do,i tot c 9,air, ion
LISE3,the f-etUl"ll A. Fadfityinaormat'
key'.
�ln ...............—
Addi c-lz oj,, t
, ss
.. ... .. ....... ......
00
/r
4 c'A . ....
wooenv 000
............ ------
C�tvTbwri,
.......... .......
LOW
2.1-*TYPE OF SEPTIC SYSTEM".1
> r p Gr�avity(cf-mose wie)
*If p urn s tf,�lru, a tita,ch Gopy of eh-,.l ctTicallpermit to�appliGation,
Go nveritional Systeiii e ir p�p
ElInfiltrator or Blod"ifftiser(Graivel--Les��,-) (Attach a copy,cd yoijr�cerfiffcatici,ri to install thlS,t )c )f M
El Prle4c;surp.Distributior'i S.A.S.(No D-Box)
Iq
.............. ............. j
x
ILI the,systemi reqtjirp. ia,ti effluent filliter?
If fi). ne ecled)
yes, does pkin specifymiake and inocle-lof fillet- YES (n of further in
NO (instalh,r 177USt specify,brcirid of filteii-befb,r(,li,DWC ISIS1.1ali'llcel)
TIE�', the
2. Owner, Itiformation
... ..,.,.... ................
J4
.................
Addre&,o(if ii,,if`ft)
o
...........
City/'Tbvii i State Zip Code
EMall adldress� "Felepl-toi-ie,t\Ilurnber
3. 1 qs,lali tier, Infort-nati'011
001,
Name Na,ri��ile of Sul fall
..........
A d d re,,s
4Y
.........
I P d
Ity/1"UM State 0 0 e
Ao
771
,13
Teleptiloj"'ie Nt,ii-i iber i(Cel/Phonc,�it if possible,plma,siq;)
4. Designer Information
0100
'0,01?z
...............................
Na m e time(-,)l"(_""("'t['n rlo
rof
0,1
00
............... ..............................................................
Address
(51
City/Fown tit Z". Code
. ............. ......
(11-3611 0,
T,e,lepi�io,r,i,eNt,,,,�T�nber(B�p.,�st#toR'each)
Applica,tion t(.)jr l"Xslj,,)csal'Slysitern Conistri,xtion Permit-Rnqe 2
AP licatimon for Se c DI 01sal System
"FODAYS DATff
0 F1"'
Construction Permit $350.00-Full Repair
A., 01.845, $175.00-Gompoiient
H ANDOVE,-�,
.......... ......
PAGE 2 O F 2
A. F a c Hit nf o S rmation co I '
"k m
I r z
c�
5. T 10 Of B Ll i I d i'n-,: 1' esid'erit"al Dweilin�g or (:-;orm-nercial
B. Agreement
The undersigned agreles,to emiure,the clonstruct t o can of ajo af6rer-des,cribed'
on-s-te sewa in accordti-nue with, the provisions of'Title-,5 of t1w,
I . ge disp,osat sy.540177 '
Environmental Code; well as th,e Local Subl,,c; c,,D,i�po,,sal' , o s f6r the T6 wrl of
p.
North Andover. fund'erstal7d'itnit until a final Certificate of Compliance has b ewrj�issueid by"
this Bbar(l of,Healthl, tti,e,ii,ist�a,li(�d,s,YSteri7 is not a1pprovec
--7 ..........
Xa 1(1�1
Applicatiori Approved E3,y,- (Boar(I of Health R(1presentativc-91
.......... ........... ..... . ................... ..............
at
Disapproved for ffle followin,g rea,,OrTs'.
"g,", musom.m
=WMUM IMAW/1"M,Wl'MmN,/,-xm====M,�
A
For Office Use 041
Tr
i� M#A � h N6
,� c'c
.............
M
3,
Ap j,:7jYca,ot rect ved is.e-�Py,-of*
nNo t es .........................
we
No,
,4. wctl a )VR all 'aw
P
As--j-;jj,,jjjj:)(t7ew construction only
6"' J�Wm)x Pl,�, w C0117structioll 014k): N'
C�xmstrixl-fion I'errni a gc, of
SEP"ric SYSTEMINSTA1,1,ER PROJECT MANAGEMENT OBLIGATIONS
,Ns di c Northd,o ver liceti,sed IllstAer for, the,, c('),ast-rucdon for the: ,gyp eptIc S, 'o-r the PI�-Op,er-ty at:
)Ir stemt
Oeoe
-em) For jAaris b
G'A'(I(IrC S of septic sysl y (Eril9ince,r)
Relative to the�ippb,cal,:iori,of
Ai,i,d,cfated
Ff
"A j,ast revised date)
tZ
r"MiffyV,
11010"
ct",M 1,g'em it's roje
1 tu,ders,tand the following obfigations �for M, ein of tl P
'I -A.s dae installic"l,- I 01)ligl'.
to, obtlai'llafl pe.i,:-.t�mtsand Bo,,,,ird of t"lealth approveld pl,a,n,sj)'r` rto
7
:at,-ty woir ite. I rnt.vst lll�,,Ctve -�-wgrk
,.kl an a s,
P I t,,he vet-,t) on, si.te wla,!�-Ij
b,e,i tig, c jorie.,
2. As t I he I tnxist call.forany "'ITI'd all-inspections. ff hatneown,er, contractor,project namiager, or may
.1 o Ildt-l"i,c sysi-cni is ready, tben
ther person not associated wi,th t'ny co,tili-P,a notny sche(ules, at'i ltJsj,.,-,)ectjon a
rl
itella thlree tr�,;Ji4ll 1:)e applicable.
I As, tlie installer I anit-eq-L�,,-red to lianre t.,I,-.i,e j,'iecessar, 'wark coin,p,eted p ior t�o the a,ppl-icable In,spect-tons a,S
y
I un,dersta,,,�nd tliat. t.it)g ,�an.1lIsr,)ec'AlL i Ill'ault CO.Pj-,1,2j ,j-iarl, (4,t"11'eitenis, in accordancc
g
W st
-ith Title 5 and 'I'llhe'Board, ofl-leq!.,!,�j ,j levied, azatin me atjA/
_j, "IlOns L In 1�1
..........
CC)I i�11 llcl�
vkrllich
less t"I'llerle is wa a. B,attom,, of"Bed t lais i,s the first (I't), ins, ecl,""IX".Al Ull P
St the, i"t i )n but does, n.otl,�i,arv,(-, to be present.
sbmlld, bc� done f1lilst. , Diu 11"Istaller t"nustreque Ispecl,
11, S COO I Ies etc.
13. Finall C"onsatic "on li"i 1", f"Ji.-sl do their insi f�, el,evatlolls,,
3, pecfto:t'i ),r
A,s--'bi:dlt,o,f''verb o lthdeptl( t.,ior�t,,.Iial.ldo,verma.,gov,) ftoi:n tlie etr.igl'lleel-M,t,lIS,,t- l�,,)e,j e-, I"o, li e,,a
a ler e-,,spectton t,tlo (:Iae Board. ofllealtl,`:I,�, 1,1"AlLfter which c, -111"s t-(,-),r am in t'tne. lnst,.] 1)
Prieset"'It tlus in.speCtl,Ofl. RUITIP SyStetlll, all elc!c�tfic-,d work Inxist be twciadlrad a ble to c m'Is,c
1,na,n:iP i,:.lo work and alarm, to
c. Flillia,-1 Grade li-Istallier reci'Liest j.Tis P ect',i,on when. ,,",111 g,-,:raLding is carnplete. Ins,taller does r,"),ot
hiavc�� t be
I\s the lin. staller I i itide,111-sta,,,nd ti-tat oll""'lly J. rn,',ay perfoj--ni the work (iv/,)ei-t1vn iwcm / n) 4,,tild I am. rcqiii-red
1L.,itic'm fu -to C0.111plete die ,1112,tion of the systctri iden.ti fied,ttiflne atltac-li.ecl applicatial,",i,,, fx-)l
tin,der'stand that done tliers gnItcensed to install,��tl,c s telms, i I n I Nordn Alj,lId,(,:)ver can C(,-,)�nlStjTLll e
y
......................................
C
ion of mv lice,ise to ""411te I J S�1�
teasons f,-(.-)r du,"llial.of tie syste.tn, incl/or rcvocation or i die '17own of
An,do sl fficant fi�nes tc), �"d NT e(i "I I- s e.
4N -4 .......
5. A�s the inst'adler 1'. tindea and tli,, t I tntist be e of the
S tep S:
3. c!t , o teatvcc aon exc s' been re%.-ichet].
,b., b."ispect'W"),t) of the sat."id iand stone to ,be, usc,(L
c., Fi'n;,il,M* 64 'on b,v Boaxtl(V71 1�*alili staff ar,consultal.l't.
d. Ins talld,ti'('l,Y,-i (:)f ta n A-,, D-Box,p p* cs, stone, 'vrcnt,,putr�p chamber, retaining walland other
6. As the installe ItttiderstanA "t,",liat I atn, sc-) elyr for the i i-istaRation of tlie,,�s v,er die
.......................... dw�
ttie o,wae -,,,enera,l cqntj:act�(�)r (�)r 4-n-
a No in,structions b r
T-r—O 'Y
ine, -obt4,,
lj i S t"'
n"ic odayr's llcic,,�rs.�ie ned llcet"i,sed ep, "
Z/Z I
c
Pfin all,"i e
C
VkORT14
+
0
J-
To,zt),n of North Andover
HEALT11 DEPARTMENT
-TA C 04U,
711,11? 21
CHECK
...........
LOCATION:
H/O NAME:
0e2 POO
Y, �Po
CONTR ACTOR. NAME,
Type_, f Permit or Licensse: (Check box)
0 Antmal
0, Bob Establishittent $
D Body Art Practitioner $
0 DuMpster
0 Food See- '
mic �ype:____,
11, Funerai'D irectors
0 Massage Estabilishnient
0 Massiage Pra,ctice $
0 Offal(Sept,10 Hauler $
1] Recreational Camp $
0 Sun tanning,
El Swittinting Pool
0 Tobacco
0 TrashlSolid'Waste Hauler
0 Well Construction $
SEPTIC System
0 Septic-Soil Testing
0 Septic-Design Approval $
Me
N, Sephc Dispolsal'Wcwks Coinstructlow(D"WC)
* Septic Disposal'Works Installeers,WWT)
* Titile 5'Inspector $
El Title 5 Report
0 Other:,(Indicate), $
Hidtth"'Agent Initials,"
White-Applicant 'Yellow,-Health, Pink-Treasurer
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