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Home My WebLink AboutDWC - tbaffle repair - Permits - 220 BOSTON STREET 10/2/2019 • yt�T.ED� Commonwealth of Massachusetts 1 1oi Lot B0o32 BOARD OF HEALTH Permit No • North Andover Q BHP-2019-0228 CO ------------------- P.I. FEE �\`Vlo $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James Boraczek --------------------- ------------------- to(Construct)an Individual Sewage Disposal System. at No 220 BOSTON STREET as shown on the application for Disposal Works Construction Permit No. B 2 -0228 VTW c ber 2019 ----------------------------------- Issued On: Oct-02-2019 BOARD OF HEALTH Application for Septic Disposal System Construction Permit — TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $7 oo-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 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 p cursor-do not use the return A. Facility Information 2� key. 'Z-2.0 Address orLot# PN CityfTown N roAll 2.-*TYPE P®p at o SEPTIC se ) LO ***If pump system,attach copyof electrical permit to application*** �FN��ppR ➢ 2qGonventionaf System (pipe and stone system) ��N��N ➢ ❑ nfiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your cerbficaflon to install this f ofsystem.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) ressur-DosEd-(rD'=rsax-rre�entil7` - ➢ ❑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) Wh2tis the Make? IX/.hatis the Modep 2. Owner Information Seca .. HIICVJ Name .)--).Q �OSTOn J 4�21?_- AddressrdMeregtfrom abgye)� Q/gy� City/Town /L7 State Zip Code G/7_ 1 16` S-29/ Email address Telephone Number a. Installer Information Z—,,mts 130,,gcu14- l)/171r'v /tip Name Name of Company L� Ic Address ns/r"CAI City/T� State Zip Code P8'y^j-S236 Telephone Number(Cell Phone#fFpossible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Bestl#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 Application for Septic Disposal System TODAY'S DATE Construction Permit - TOWN OF $350-00-Full Repair NORTH ANDOVER, MA 01845 $75 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. 1 understand that until a final Certificate of Compliance has been issued by this Board of Health,the installed system is not approved. Na Date App i ation p .rove Ji By: (Board of Health Representative) "fit cJ L IS Name Date 1 Application Disapproved for the following reasons: For Office Use Only: j Z Fee Attached? Yes 4' / No ✓ Z. ProyectMaztaget'Oblrgatzoxz Form Attached Yes No 3_ Pzzmp Svsteru Ifso,Attach copy ofElectzicalPexmrt Yes o Applic2ntreceived copy of `fElectricallrzspectzoxi Notes for Septic Systems" es No Handout? 4. .Reviewedapprovalletter, allpaperworkreceiveda Y o IWssxrzg_ 5. Fou-ndationAs-BaUt?(new construction only): s No (Same scale as apptovedplan) 6. Floor Plans?(new construction only): � Application for Disposal System Construction Permit•Page 2 of 2 I SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction fox the septic system for the property at: Z,2.C� �OS7f'�✓ S� (Address of septic system) For plans by (Engineer) Relative to the application of (Iastaws name) And dated n to Dated /y o a s ate With revisions dated (Last mvised 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 ap2roved 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 m�compan� a. Bottom of Bed—Generally, this is the first(1�inspection unless these 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 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 map perform the work (other than simple excavation)and I am requited 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: (Today's Date) /U�� y QMrS /Jd/ C-'ZC ame— mt ame—Signed) O`NORTM 1y fit/ aJ ". Town of North Andover HEALTH DEPARTMENT �SS�cHug�� CHECK#: DATE: IC) ` LOCATION: O /30 5 fd s' H/O NAME: /fir/��G CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ E ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ E ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrasIVSolid Waste Hauler $ C ❑ Well Construction $ r SEPTIC Systems: ❑ Septic-Soil Testing � / $ ❑ Septic-Design Approval !, 1 Septic Disposal Works Construction(DWC) $�'7-5— ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ E` i s ❑ Other. (Indicate)— HeaWAgent Initials White-Applicant Yellow-Health Pink-Treasurer