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HomeMy WebLinkAboutDWC Permit - Full Repair - Permits - 61 FOREST STREET 10/21/2019 Fie}��'.F°� Commonwealth of Massachusetts Commonwealth • 106.A0168 BOARD OF HEALTH ----------------------- Permit No North Andover BHP-2019-0230 ----------------------- FEE $350.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James Boraczek to(Construct)an Individual Sewage Disposal System. at No -1 FOREST STREET as shown on the application for Disposal Works Construction Permit No. B -0230 a Octo er 2 19 -1� ---------------------------------- Issued On:Oct-21-2019 BOARD OF HEALTH S afilfth Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF $350.00-Full Repair NORTH ANDOVER, MA 01845 $75 00-Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* ` ® forms on the computer,use Xkepair or replace an existing on-site sewage disposal system* only the tab key []Repair or replace an existing system component—What? to move your cursor-do not use the return A. Facility Information key. Address or Lot# r�s A/AUP-0vtr City/Town 2.-'TYPE OF SEPTIC SYSTEM': ➢ ❑Pump WGravity(choose one) ***If pump system,attach copy of electrical permit to application*** ➢ ❑Conventional System (pipe and stone system) ➢ Dnfiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type ofsystem.) ➢ ❑ ressure Distribution S.A.S.(No D-Box) - .. .➢U`rre'��saFe`il.os'ea-(1J=60)4.I'f���f7i)-�-,Er-S.: .•._ ._. ---- ---- ➢ ❑Does the system require an effluent filter? Yes No If yes, does plan specifymake and model offilter? YES=(no further into.needed) NO =(installer must specify brand of filter before DWC issuance) Tffzatis the Make? What-is the Model? 2. Owner Information SCo —' Coo Name Sgf-L C, Address(if different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information -��Ivl�S a�q�tc!( Qr$Ct-cl��1 SSA1�i� ¢ Dr u'v tvc Name Name of Company q2c I r Address -A4,41 P5 11r1f y��y 1 City/Town I State Zip Code onz- s23 6 Telephone Number(Cell Phone#ifpossible please) 4. Designer Information_ , t,) I/ VA,y �N i'nrcCr!'M .��tva �CC Name Name of Company PO (3d;( ZoQy Address ©n 8 2, CA,I o�iC,rN � CityfTown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 9/1'.��� 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: Azesidential 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. e Date Appli • n Appro y (Board o Health Representative) z Name Date Appli ation /sapproved for the following reasons: For Office Use Only: Yes No 1. Fee Attached? Z. PtojectManaget Obligation Fora Attached. Yes (� No S stem? If so,Attach co ofElecttical Petrnit Yes No 3. Pump y , copy Applicant-received copy of "Electticalinspection Notes fox Septic Syste-ms" Yes No Handout? 4. Reviewedapptovallettex, allpapetwotkxeceived? Yes No Missing. 5. Foundation As-Built?(new construction only): Yes — (Same scale as approved plan) 6. Flo otPlans?(new construction only): 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: � � ,fur{r� s� S U11 �U (Address of septic system) For plans by (Engineer) Relative to the application of J clyht d /?a r aIL (Installer's name) And dated KZ 20 l Q ngtn ate f Dated _21-1 2o ay s ate With revisions dated VD (Last revised date) I understand the following obligations for management of this project: 00 2 ppVER loo�F NpE - V0J ri 1. As the installer,I am obligated to obtain all permits and Board of Health approved plans or t�,F�LJx 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(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 OK (or e-mail to:healthdeptntownofnorthandover.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: �G�N2P✓ ���,,4C7_eIL (Today's Date) (Name— not amSigned) Gf MORT f r Town of North Andover ;'•�:,;:s HEALTH DEPARTMENT �ss�cHus�� CHECK#: DATE:/O -�/-a0/� LOCATION: J`-'6 H/O NAME: .5hor/7/ CONTRACTOR NAME:-ZRA12.5 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 L)'� $ ❑ Septic-Design Approval $ ' 0 Septic Disposal Works Construction(DWC) ❑ Septic Disposal Works Installers(DWA $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer