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Home My WebLink AboutDWC Permit - New Construction of Septic System - Permits - 1985 SALEM STREET 9/25/2019 Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALTH ------------- Permit No North Andover BHP-2018-0269 BHP- 01 ----------- FEE $350.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Dave Maynard_- - ---------------------------- to(Construct)an Individual Sewage Disposal System. at No 1985 SALEM STREET as shown on the application for Disposal Works Construction Permit No. BHP-2018-02 ated e cr 0 018 Issued On: Sep-06-2018 BOA OF HEALTH f/ V//')? 3 4 ✓)?de_V-'-) / C/ooci rrnl)? 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 fora permit to: When filling out Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key ❑ Repair or replace an existing system component—What? to move your cursor-do not use the return A. Facility Information L key. 12 X5 S.�/-c--� s Address or Lot# � rye /1k. �Q-•-�oc.—i fj9L.. City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump [4- vity(choose one) ***If pump system, attach copy of electrical permit to application*''* ➢ [A-CZ_nventional 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(DwBox-P resent)SSA a�--_--- ➢ ❑ 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) Who tis the Make? What is the Model? 2. Owner Information 4 t Name Address(if different from above) City/Town State Zip Code 927 - 6y0 - Email address Telephone Number 3. Installer Information ��J c• //// ��,(!)/ ,o JV'-f_ `i i�'�-f sv A v�L i"-9 iiJ/+u w.0'rI•vC/!v t l o Name n Name o ompany ,�7 Z c"' be , '_ _:T—s 1 Address e6�! 4) // B 3 2 z Sr Cityfrown State Zip Code 97 ,F- 72z9- Telephone Number(Cell Phone#if possible please) 4. Designer Information fA,/ Name Name of Company 16(2 Su,-- -L,e 6,t- s Address 3 City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 A0% 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 Board ealth, the instal ed s stem is pproved. ?z' Name Date A li AbApprove ,: (Board of He�lth Representative) Na Date Application Disapproved for the following reasons: For Office Use Only: Z Fee Attached? Yes/ No 2. Project Manager Obligation Form Attached.? Yes/ No 3. Pump System? Ifso,Attach coy ofElectrical Permit Yes NoK Applicantreceived copy of "EleaticalInspection Notes for Septic Systems" Yes No Handout? 4. Reviewed a PP rovalletter, allPaP erworkreceived? Yes v No Missing. 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) G. Floor Plans?(new construction only): Yes 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: (Address of septic system) For plans by /p`tn ,s /,; -S--< 0 (Engineer) � Relative to the application of �j��- f l�tJ�� C/ (Installer's name And dated ,�J l�/ —261 17, rl to Dated 9�� /j f � o ac7yTs crate 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 Pho-r 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 (V5 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. Finalinspection 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 ap roved 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) ame—Print) (Name—Signed)' O` MOP7:,y V 4 C, l Town of North Andover `;'•�,;;o:: ,' HEALTH DEPARTMENT �S4C U �t CHECK #:;10 DATE: LOCATION: -- 7 s,rV 5 H/O NAME: /�; ► -� o ? _�,� CONTRACTOR NAME: tx. 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 $ � 1 Septic Disposal Works Construction(DWC) $f` ,j- 1 , ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ It`eatth"Agent Initia White-Applicant Yellow-Health Pink-Treasure