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Home My WebLink AboutD-box Repair - Permits - 107 SUMMER STREET 10/16/2019 Commonwealth of Massachusetts Map-Block-Lot 4iio 038.00252 -- BOARD OF HEALTH Permit No North Andover BHP-2019-0229 ----P-20-9-02------ P.I. FEE F.I. $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John L. D1Vlncenzo to(Construct)an Individual Sewage Disposal System. at No --107 SUMMER STREET --------------------------- as shown on the application for Disposal Works Construction Permit No. - 9-_M? b 9 ------- ----------------------------------------------- Issued On: Oct-16-2019 BOARD OF HEALTH s Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF $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 ❑Repair or replace an existing on-site sewage disposal system* ^/ only the tab key to move your P-Frepair or replace an existing system component—What? cursor-do not use the return A. Facility Informa 'on key. Address or Lat# OCT CWTown 2.--TYPE OF SEP SYSTEM: TOH�LTH pEPAR MENF t4ORIH `TR > ❑rump FerGravity(choose one) "f pump system,attach copy of electrical permit to application*** ➢ ❑Conventional System (pipe and stone system) ➢ ❑Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of yourcertificafion to install this type ofsystem.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) - - -- - u.ossa-(u=�ox_rr-e s-enrl'�. .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) Wjwtzs theMake.� Whatis the Model? 2. Owner Information Name /o� Address(if d' rent from ove) Oop z City/Towrr State e Zip Code Email address Te ephone Number 3. Installer Information Name Name oMo ippany Addre 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 o-rj jde,ve-A�Dmu t J h04/Y)CL-,,/. C0M Application for Septic Disposal System TODAY'SDATE 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-sites arc e disposal system in accordance with the provisions of Title 5 of the En "ron tal We, well as the Local Subsurface Disposal Regulations for the Town of N h A ver I n rstand that until a final Certificate of Compliance has been issued by th Bo r of e e installed system is not approved. Date Applicatippro : (B d of Health Representative) me Date Applicatio Disapprove or the following reasons: For Office Use Only: Z Fee Attached. Yes No Obli atian Form Attached. es� No 2. Ptolect Manager g 3. Pup Svstem? Ifso,Attach copyofElectrrcalPetmit s No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Ye o Handout? 4. Reviewedapptovalletter, allpapetw rkreceived? Yes N Missing.- 5. Foundatio-n As-Bwli?(new construction only): Yes o (Sarre scale as approved plan) 6. Floor Plans?(new construction only): Ye 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: /02 5L2, r71 YA c k--- �,- fi (Address of septic system) Fox plans by �—� (Engineer) Relative to the application of V)Yu Ce 006 qnstaRer's name) And dated date) Dated //c7:/- -/"a3r's ate With revisions dated (Iasi 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 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 OIL(or e-mail to:healthdept@northandove=aa.gov)-ftom..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 excavalfon)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 ate 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. Fznalinspection by Board ofITealth staff or consultant. d. Installation of tank,D Sox,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: y's D e) )61M L V14 Ae—1/-1 lvzop' ame— rint —Signed) Of MORTM 1y 8 / v .� O F�.+�•',ram`i�L9 • . Town of North Andover HEALTH DEPARTMENT ssACMu,+t CHECK#: 7 5 DATE: /Q - ,�-FOR LOCATION: AD'? Sc j on 4x/' .� . 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 $ PSeptic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ _ atth Agent Initials White-Applicant Yellow-Health Pink-Treasurer