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Home My WebLink AboutDWC Permit - 04.16.2019 - Permits - 50 SAW MILL ROAD 9/13/2019 • <<��.� Commonwealth of Massachusetts Map-Block-Lot - s . • 104.A0086 BOARD OF HEALTH ----------------------- Permit No North Andover BHP-2019-0075 P.I. ----------------------- FEE F.I. $350.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James Kellett to(Construct)an Individual Sewage Disposal System. at No 50 SAW MILL ROAD - --------- as shown on the application for Disposal Works Construction Permit No. 13HP-20191_075 D 16,20 -- - -- -- ---- -------------- Issued On:Apr-16-2019 ---- =- BO OF HEALTH r Application for Septic Disposal System !�DATE v o q T AY'S Construction Permit — TOWN OF $350.00-Full Repair NORTH ANDOVE% �VJ_L�. 01845 $75.00-Component Important: Application is hereby made for a permit to: �� When filling out [I Construct a new on-site sewage disposal system* GV forms on the computer,use kRepair or replace an existing on-site sewage disposal system* IV only the tab key to move your ❑Repair or replace an existing system component—What? cursor-do not pF N boy use the return A. Facility Information �N �N key. f5—O 3 4. ,� AA t Address or Lot# Qnc�z Je a City/Town few° 2,*TYPE OF SEPTIC SYSTEM': ➢ ❑Pump X Gravity(choose one) ***If pump system, ach copy of electrical permit to application* ➢ ❑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) o_. _. _ _r _ ---------- - - .. .�-U:r.Fe��ufe u.os�a"('i)-raox r'Fe�snt/'�.�.a: -.- .--- ➢ 9 Does the system require an effluent filter? Ye No If yes, does plan specify make and model of filter? YES no further info.needed) NO_(installer must specify brand of filterbefore DWC issuance) WMat-is the Make? •V,�j C(! Whatis t ,Model? 2. Owner Information f-j g/7 /<_ L_kz sA Name S A w .n� l c L lZ 1� Address(if different from above) City/Town State Zip Code 2 tS f -- '7 5 Email address Telephone Number 3. Installer Information Name Name of Company Address -r' C � /"�A 7 f✓) Ciwrc) State Z' Code Telephone Number(Cell Phone#h possible please) 4. Designer Information { Name. Name of Company Address C> 13 d1 MIAO1 'FeeCityrTlo_Jw,nn State Zip C de Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 t Application for Septic Disposal System T AY'S DATE Construction Permit - TOWN OF $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component PAGE 2OF2 A. FacilitV Information continued.... 5. TVpe 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 a the Local Subsurface Disposal Regulations for the Town of Npjh Andover. I and stand a ti a final Certificate of Compliance has been issued by i Board of Health a ins d s em is not approved. P o2ae Date App�' to pp ve B : (B and of Health Representative) Name Date Appli ation Di pproved for the following reasons: For Office Use OnIV: 1. Fee Attached? Yes_/ No 2. Pxol ectMam agObli et ation Form Attached? Yes�/ No g 3. Pump Svstetn? If so,Attach copy ofElecttical Petit Yes No AppEcantxeceived copy of "ElectricalInspecdo-D Notes fox Septic Systems" Yes No- Harzdout? etter, all etwo a rkxeceived? Yes j_ No 4. Rer�ewed approvall p p Missing. 5. Fozwdatzon As-Built?(new construction only): Yes No (Same scale as approved plate) / G. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit.Page 2 of 2 r .• 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) Fos plans by Relative to the application of�w��,S G e pp V J� * And dated ,Se 02 V L (IastaIlei's name) p, Dated l O 2,6 i O c.- Z e? ZO g o ay's date) 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 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 companT- 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 OIL(or e-mail to healthdept@northandoverma.gov) from the engineermust 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. Detexmznation that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Finalinspection by Board oflTealth staff or consultant. d Installation of tank,D-Box,pipes, stone, vent,pump chamber,retaining waft and other components. 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: 24,/ (Today'ss Date) (Name— not a igne 85910 O,NORTM 1y �` 3? •„ e, �•Doc Town of North Andover '+�'••;;;,; : HEALTH DEPARTMENT �sswcNustt CHECK#: 6 8 8 DATE: -A-�419 LOCATION: 6- H/O NAME: l CONTRACTOR NAME: Ae.lfe.l7� 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 1 J $ ❑ Septic-Design Approval (ram Da ( $ Septic Disposal Works Construction(DWC) $ 3 5 Q ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ He Agent Initials White-Applicant Yellow-Health Pink-Treasurer