HomeMy WebLinkAboutDWC - Dbox repair - Permits - 40 CEDAR LANE 8/1/2019 i
•,�q;.pGfib;r�a' • Commonwealth of Massachusetts Map-Block-Lot
106.A0141
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•
BOARD OF HEALTH Permit No
North Andover -BHP-2019-0177----
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FEE
$17 .00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John L. DiVincenzo
to(Construct)an Individual Sewage Disposal System.
at No LANE
-40-----------CEDAR-------------------------------------- - ----------------------- --------------- --- ------------------------
as shown on the application for Disposal Works Construction Permit No. 019-0177 1
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Issued On:Jul-31-2019 BOARD OF HEALTH
i
•�� ••��•. Application for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Components
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 E] Repair or replace an existing on-site sewage disposal system*
only the tab key to move your R Kepair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
key.
Address or Lot# i
� � I
city/Town 12p19 �'
2.-*TYPE OF SEPTIC SYSTEM
e one)
***If pumps Pumpm, attach copy of elects al permit to application*** pF N0R1N 1MEiv
➢ Conventional System (pipe and stone system) ���Ep� �'(N�EpAR
➢ ❑Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification fo install this type of system.)
➢ ❑ Pressure Distribution S.A.S.(No D-Box)
--.._..------__—---.:➢:.,E__]-_r ressure-Dosed-(D=i3ex_-Presont,rS: -5---. .... :., --------
➢ ❑ 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 Make? What is the Mod&?
2. Owner Information
i/AAA �i�L
Name
117
Address(if differe from ab ve)
BUD ��cr
City/Town State �i Zip Code
Email address Telephone Number
3. Installer Information
Name ° Name of Company
Address
VQ
City/Town State
�iz�
(�—
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
•�,,;u° - Application for Septic Disposal System
Construction Permit — TOWN OF TODAY'S DATE
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: ❑Residential 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 ell as the Local Subsurface Disposal Regulations for the Town of
No h n v r, unde stand that until a final Certificate of Compliance has been issued by
th" B r e Ith, a installed system is not approved.
r
N e Date
Ap 'c on A rov d B . (Board of Representati7)/70119
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee AttacbedP Yes✓ No
Z. Project Manager Obligation Form AttacbedP Yes No
3. Pump S sY tern? Ifso,Attach cop ofElectrical Permit Yes No
Applicantreceived copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed apprrovalletter, aRpaperworkreceived? Yes No
Missing.• I
5. Foundation As-Built. (new construction only): Yes No
(Same scale as approved plan)
6. F1oorPlans?(new construction only): Yes No
Application for Disposal System Construction Permit-Page 2 of 2
Of NORT.,� 6697
0 •-r' • T
f . Town of North Andover
�•- .: ,' HEALTH DEPARTMENT
,SSACNUSt4 �
CHECK#: 18.531DATE: - m,3/��
LOCATION: �� (. �� zo_nP-
H/O NAME:
CONTRACTOR NAME: 04tl
`5 e cc)cz/' S
r
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type. $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
Septic Disposal Works Construction(DWC) $ "
❑ Septic Disposal Works Installers(DWI) $
0 Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $ I
Xth Agent Initials
a
White-Applicant Yellow-Health Pink-Treasurer
4
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