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Home My WebLink AboutDWC Permit - dbox & outlet tee repair - Permits - 32 EQUESTRIAN DRIVE 8/6/2019 FILE COPY Commonwealth of Massachusetts Map-Block-Lot 105.D0139 BOARD OF HEALTH Permit No BHP-2019-01e0 North Andover FEE x Y -----------$175.00 -- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted ------------------------------------------------- ------ to(Construct)an Individual Sewage Disposal System. at No -32-EQUESTRIAN DRIVE ---- ----- - - - as shown on the application for Disposal Works Construction Permit No. 19-0180 D Augus )�9 Issued On:Aug-05-2019_ BOARD OF HEALTH I Application for Septic Disposal System `��/ a. TODAY'S DATE F Construction Permit - TOWN OF j ,.� $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* I forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab keyQ46"pair or replace an existing system component—What? �a to move your w cursor-do not use the return A. Facility Information key. �V Address or Lot# AUG U , 2019 v � Cityrrown . TOWN OF NORTH ANDOVER 2.-*TYPE OF SEPTIC SYSTEM*: HEALTH DEPARTMENT ➢ ❑ Pump ravity(choose one) ***If pump syst ,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 Make? Wbatis the Model? 2. Owner Information Name ` Address(if different from above) 0LV_° , Mom, City/Town State Zip Code C17AF g®vy- G&Srl Email address Telephone Number 3. Installer Information Name Name r INC. r ! ArO4 ( - 111 ARGILLA ROAD Address ANDOVER, NIA 01810 CitylTown State Zip Code 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) i Application for Disposal System Construction Permit-Page 1 of 2 i � I l r �°y Application for Septic Disposal System TODAY'S DATE Construction Permit - TOWN OF $350.00-Full Repair NORTH ANDOVER, NA 01845 $175.00-Component PAGE 2OF2 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. I_understand that until a final Certificate of Compliance has been issued by this Board oJ49alth,the installed system is not approved. Name Date Applicati Approve oaid o ealth Representative) Namel Date Application Disapproved for the following reasons: f I For Office Use On 3 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump S sy tem? Ifso,Attach copy ofEleetrical Permit Y Applicant received copy of "Electrical Inspection Notes for Septic Systems" Handout? 4. Reviewed approval letter, all paperwork received? Yes_ No Missing.• 5. Foundation As Built?(new construction only). Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only). Yes No Application for Disposal System Construction Permit•Page 2 of 2 r � 1. SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS i As the North Andover licensed installer.for the construction for the septic system for the property at: (Address of septic system) For plans by (Engineer) Relative to the application of ,4 (Installer's name) And dated ngina date) Dated c (Ioclays ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am obligated to obtain all permits and Board of Health approved plans prior 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 3 indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50 00 fine being levied against me and/or my co=9A j a. Bottom of Bed—Generally,this is the first(V)inspection unless there is a retaining wall,which should be done 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: healthdept@townofnorthandover.com) from the engineer must 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 I may perform the work(other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further j 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 Town of tl I! 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: f 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. j 6. As the installer,I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) ao ame—Frint) ame—Signed) ii I NORTh - 8704 : :• Town of North Andover `,�•- ,;.` ,' HEALTH DEPARTMENT ,,3$ CHUStt CHECK#: ;�5� DATE: O/? LOCATION: 3), G'��) � �'' - AK H/O NAME: Gt- 00,dr CONTRACTOR NAME: 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 �kjU" $ ❑ Septic-Design Approval aldJ� Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) ❑ Title 5 Inspector $ a Title 5 Report $ ❑ Other:(Indicate) $ I 4Healtg t Initials White-Applicant Yellow-Health Pink-Treasurer