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Home My WebLink Aboutd-box - Permits - 48 WINDSOR LANE 11/15/2019 •' Map-Block-Lot .TcLED,� � Commonwealth of Massachusetts 106.D0072 6.DO BOARD OF HEALTH Permit No North Andover BHP-2019-0237 P.I. FEE --- F.I. $175.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James-Boraczek to(Construct)an Individual Sewage Disposal System. at No 48 WINDSOR LANE ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2 9- 7 Dat er 2019 --------------------------- ----- - ----- ---- - Issued On:Nov-15-2019 BOARD OF HEALTH t { ,Application for Septic Disposal System TODAY'S DATE Construction Permit - TOWN OF $350.00-Full Repair NORTH .ANDOVER, NU 01845 $175 00-Component Important: Application is herebV made for a permit to: `, O When filling out ❑Construct a new on-site sewage disposal system* forms on the F computer,use ❑Repair or replace an existing on-site sewage disposal system* 2�19 only the tab key XRepair or replace an existing system component--What? l /3o)C NQV 1 to move your Na0 cursor-do not �Q use the return A. Facility Information SQWNQ�O� key. �$ tV jlq r LN /U"79YL1 0 -V t r Nam' Address or Lot# r� Al,-4y PovV City/Town few" 2.- TYPE OF SEPTIC SYSTEM : ➢ ❑Pump Gravity(choose one) ***If pump system,attach copy of electrical permit to application' ➢ Conventional System (pipe and stone system) ➢ n Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy ofyour certification to install this type of system.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) •- - -➢LJr.re��safe`ilosea-(v=i�ox r-Ee�snij�s:f�.�.:. ... ..._ ➢ ❑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 Makep Whatis the Model? 2. Owner Information Name�zS al y`M d sd rr �!Y Acldress(if different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information Joll"�� prgcze/L 0C-Ukl StDpc f-Ve-0,V f L Name Name of Company Address dog na ft ,l N'l 0��`�/ Clty/T� State Zip Code tOM-1- cl- 523& Telephone Number(Cell Phone#ifpossible please) 4. Designer Information o r�ut.J�.SSe plt►Y Q G��;�, 0A, Name Name of Company Address CitylTown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF NORTH ANDOVER, M.A. 01845 $75.00-component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building.AResidential 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 Application Approved By: (Board of Health Representative) Il S 9 Name Date Application Disapproved for the following reasons: For Office Use ®nly: 1. PeeAtfached? Yes No tzon Fora Attached. Yes No Z. P,torectManaget Oblrga 3. Pump 3 sy texas? Ifso,Attach comp ofElectdcal Permit Yes N AppAcant-received copy of `!EIectdcallnspection Notes fox Septic Systems" Yes N Handout? 4. Reviewed approvallettet,allpapetwotk.received? Yes No Mrssrng:- 5. Found ationAs Built?(new construction only): Yes o (Same scale as apptovedplan) 6. P70oxPl2ns?(new construction only): Yes N 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: (f (Address of septic system) Fos plans by 1" 45;effta PP y ah2{f (Engineer) Relative to the application of /?aolCz e-� (InstsWsname) And dated A4/ Z-7 'ZL-r"Y to Dated //'/�`/9 o a slate) 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 prior to performing any work on a site. I must have the approved plans and the permit on site when any words 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/ox 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).fr-om.the-engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installet 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 axe also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Detatmi6atzon 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,retazning wall and other components. 6. As the installer; I understand that I am solelly 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: (To'day's Date) —!AFMr S /.30 C2aV6 �r / — - (Name— tint aiYe igne O1 NOAT1y 1 �.. t p • • Town of North Andover HEALTH DEPARTMENT 34CHUS! c �q CHECK#: DATE: LOCATION: �/8 J [! cAq H/O NAME: LLR e� CONTRACTOR NAME: �' P.�G 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 S.sten:s. ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ 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