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Home My WebLink AboutDWC Permit - d-box repair - Permits - 40 STERLING LANE 9/16/2019 • 5�`"�"' Commonwealth of Massachusetts Map-Block-Lot 106.00036 BOARD OF HEALTH --------------------- Permit No North Andover BHP-2019-0215 ----------------------- FEE $175.00 ----------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted -- -- to(Construct)an Individual Sewage Disposal System. at No 40 STERLING LANE ----------------- as shown on the application for Disposal Works Construction Permit No. BHPI,4612.4215 p ep ber4 2019 slue On: Sep-16-2019 ---------- -- ------------ ---- BOARD OF HEALTH r,z,� ,, •. Application for Septic Disposal System 'S Construction Permit — TOWN OF TODAY DATE $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* forms on the computer,use ❑ Repaj'T or replace an existing on-site sewage disposal system* only the tab key to move your epair or replace an existing system component—What? d y� cursor-do not GO use the return A. Facility Information I /� _"' G/►��v key. 7.* S �ttl-ii✓Si /�/�. R�V Address or Lot# n3 City/Town 2.-*TYPE OF SEPDQ SYSTEM*: ➢ ❑ Pump Enravity(choose one) ***If pump system, attach 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) ➢ ❑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_ Name Address(if different from above) Cityfrown State Zip Code Ile aj Y—/3,1-X Email address Telephone Number 3. Installer Information Name Name of Comp ARUILLA 1iUr.0 /i l An, t(.4 RtJ AND0VE --- Address /A n City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address Citylrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 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 Buildinq: ❑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 Board of Health, the installed system is not approved. /14-9 Name Date e Applicatidry r e By: oard of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: I 1. Fee Attached. Yes No 2. Project Manager Obli ationFormAttached? Yes No 3. Pump S s� tem? If so,Attach copy ofElectttcal Permit Ye o Applicant received copy of "Electrical Inspection Notes for Septic Systems" Ye Handout? 4. Reviewed approval letter, all paperwork received. Ye _ Missing.• 5. Foundation As Bui*?(new construction only): Y s (Same scale as approved plan) I 6. Floor Plans?(new construction only): Y s No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: 47D c5T e,-[.;.may 4. (Address of septic system) For plans by �^ n (Eng neer) Relative to the application of �� Sy/✓ (Installer's name) And dated (Ong a ate Dated -!— 3 �I o ayes date With revisions dated st re ised date) I understand the following obligations for management of this project: I 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 company. a. Bottom of Bed—Generally,this is the first(1')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 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 of Health 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 approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: z (Today's Date) 9 /3 (Name— rint ame—Signed) Of NORT.,h V / J 5 O • Town of North Andover `ti'•e;;;;..'t,' HEALTH DEPARTMENT ,SSACMIS�S CHECK#: (03 DATE: 9-/3 _,ZO) LOCATION: 1/0 S -/' ' C/ H/O NAME: �7 jQzfe4 ics" CONTRACTOR NAME: Q_be-Sa zo 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) $7= ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ! ❑ Title 5 Report $ i ❑ Other:(Indicate) Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer