HomeMy WebLinkAboutDWC Permit - Permits - 562 BOXFORD STREET 9/11/2019 • Commonwealth of Massachusetts Map-Block-Lot
105.00003
BOARD OF HEALTH -----"""
Permit No
North Andover BHP-2019-0211
FEE
$350.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted - -
to(Construct)an Individual Sewage Disposal System.
at No 562 BOXFORD STREET
----------------------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2019-0211 Date ber 11 2019
----- ---- --- -- - - ---------------------
Issued On: Sep-11-2019 OA O HEALTH
Application for Septic Disposal System '
Construction Permit — TOWN OF TODAY'S DATE
$350.00- Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
_ .Gn
Important: Application is hereby made for a permit to: � vm
When filling out ❑ Construct a new on-site sewage disposal system* �N
forms on the �a
computer,use Repair or replace an existing on-site sewage disposal system* VG'
only the tab key ��' PNco
to move your ❑ Repair or replace an existing system component—What.
cursor-do not OF
use the return A. Facility Informmatio
key. S� '2. tJc K 1) j /Sr
Address or Lot#
l406vxr".-/4 anSf4'Ile f- ' jk ,% ie,tier0) mai� Ca�+t
City/Town
rerun 2.-*TYPE OF SEPTIC SYSTEM*:
➢ 7RPump ❑Gravity(choose one)
***If pufi7p system, attach copy of electrical permit to application***
➢ Z Conventional 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? What is the Model.
2. Owner Information `, /(.. a m e S
Name /
�(7 &2 x 7(Vrd
Address(if different from above)
City/Town Stale Zip Code
Ke.TDE2--:y °e ,
Email address Telephone Number
3. Installer Inform'ratio j
el e�— v11 Ii'1�f
Name Name of Company
l 2. Fr f_Sly AUt
Address
le-ijksiv,-s- L OMA 141A 7wl
City/Town f State Zip Code
972 _ , a iy3-5-
Telephone Number(Cell Phone#if possible please)
4. Desiciner Information
Tlpt
Name V Name of Company
160 .Su,i m,-r V.
Addre
74/ v�o 11i &
City/Town State Zip Code
'?79'- 373 -• G316
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
•A,;,.° Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
$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 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 of Health the installed system is not approved.
e Date
Ap ation,A roved By: (Board of Health Representatit
1.L ( i
Na Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached.? Yes No
2. Project Manager Obligation Form Attacheda Yes No
3. Pump S sy tem? If so,Attach co y of Electrical Permit Yes No
Applicantreceived copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed approval letter, allPaP erworkreceived? 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
Of
0?
• Town of North Andover
HEALTH DEPARTMENT
,S3ACHUStt �
CHECK#: 00 DATE:
LOCATION:
H/O NAME:
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 � $
❑ Septic-Design Approval 0 $
Septic Disposal Works Construction(DWC) $-.
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
g1
i
1
1th Agent Initials'
White-Applicant Yellow-Health Pink- Treasurer
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(address of septic system) For plans by C--/�l s/'I W se n N/
(Engineer)
Relative to the application of �2And dated /� /z
(Installer's name) /Q Q
��gui ate '
Dated 9 /I A Q/
o ay s ate With revisions dated -S-,X8_//F7
(Last revised date) 0-401
I understand the following obligations for management of this project: le,
C�
1. As the installer,I am obligated to obtain all permits and Board of Health approved plans nio �Qp
performing any work on a site. I must have the approved plans and the permit on site wlzei tfi ork 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
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 company
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@northandoverma.gov) 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
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
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:
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 ofHealth staff or consultant.
d. Installation of tank,D-Box,pipes, stone, vent,pump chamber,retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
apl2roved plans. No instructions by the-homeowner. general contractor, or pny other persons shall absolve
me of this ob ' lion.
Undersigned Licensed Septic Installer: (Today's Date)
(Name—Print) (Name—Tigne