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Home My WebLink AboutDWC - dbox repair - Permits - 1317 SALEM STREET 11/13/2019 f t. dgi& 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 [''Repair or replace an existing on-site sewage disposal system* only the tab key to move your 'XRepair or replace an existing system component--What? - AV y cursor-do not use the return A. Facility Information RECEIVEDkey. Address or Lot# 4 7019 �s /+« e,r O/m City/Town TOWN OF NORTH ANDO HEATH DEPARTMENT 2.- 'TYPE OF SEPTIC SYSTEM": ➢ ❑Pump ravity(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) .. .➢—'L�j�rPe��ue�`ir.os�d'(ii=uox c'Fe�eni)-�-ifi:o:. . ... .... ---- ---- ➢ ❑Does the system require an effluent filter? Yes No X If yes, does plan specify make and model of filter? YES =(no further info.needed) NO=(installer must specify brand of filter before DWG issuance) YY.tutis the Make? Matis the Model 2. Owner Informations k)Ij e- �a�✓�� Name _7/ 7 O L)-1e,N Address(ifdiffereenntfrom above) N � M 0 -e CitylTown State Zip Code Email address Telephone Number 3. Installer Information Name Name of Company fie,.4 /P_/'aay ST' Address /I/ . ri ol� �.z /" o i�v -' Citylfown State Zip Code Telephone Number(Gel[Phone#if possible please) 4. Designer Information Name Name of Company Address CitylTown State Zip Code Telephone Number(Best#to Reach) i Application for Disposal System Construction Permit-Page 1 of 2 � � ov 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: d/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. 1 understand that until a final Certificate of Compliance has been issued by this Board of Health, the ins t ystem is not approved. `% Name Date Ap4*onoved 13y: (Board of Health Representative) f1 c `1 Nam Date Application Disapproved for the following reasons: For Office Use Only: J 1. Fee Attached. Yes ✓ No 2. Pro ectMatza et Oh.0 ation FoLm Attached. Yes" No 1 �' g 3. Pump Systcm Ifso,Attach copy ofElecitical Petznit Yes No_K Applicantx-eceived copy of "Electdcallvspection Notes for Septic Systems" _ o Handout? 4. Revtetivedapptovallettet, allpaperwotkreceivedP T' � Missitig.- 5. FoutldadoxzAs-Bzdlt?(new construction only): Yes (Same scale as approved plan) G. Floor Plans?(new construction only): Y No Application for Disposal System Construction Permit•Page 2 of 2 Cf NOR TI/1y V t. `. 9 Town of North Andover ,x" CHU5�4 HEALTH DEPARTMENT CHECK#: //(90 DATE: LOCATION: /3 /7 3�./e m H/O NAME: / 00 Ver CONTRACTOR NAME: -D l Qr- 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 �" x-+ $ 1J, Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: /S.).7 45�A, e, f 9 4-- (Address of septic system) For plans by Relative to the application of "'i 6'0%g_q( �Iast9l�eiss�) .And dated to Dated //— o a s ate With revisions dated • (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I ana 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 recluesfM 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@northandoverma.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 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 ofHeahh 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: /f ' N` q (Today's Date) 7Jf'-n' G (Name—Print) ame-Signed) Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALTH 106.A0124 ------------- Permit No P.I. North Andover BHP-2019-0236 ----------------------- F.I. FEE i $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Daniel A. Giard - ------------- to(Construct)an Individual Sewage Disposal System. at No 1317 SALEM STREET --------------------- - - - - - - - ----------------- -as shown on the application for Disposal Works Construction Per No. BHP-2 ------------------ 9-0 6 Dat er 14,2019 Issued On:Nov-14-2019 ------------------ -------------------- - BOARD OF HEALTH