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Home My WebLink AboutDWC Permit - dbox & outlet baffle - Permits - 755 JOHNSON STREET 11/18/2019 • yYrnEDj Commonwealth of Massachusetts Map-Block-Lot 038.00069 BOARD OF HEALTH Permit No North Andover -BHP-2019-0238------------- ----- ---- FEE $175.00 ----------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Dean Dynan to(Construct)an Individual Sewage Disposal System. at No 755 JOHNSON STREET ---------------------------------------------- ------(9-0238 ------------ as shown on the application for Disposal Works Construction Permit No. B D 9 ----------------------------------------------------------------- Issued On:Nov-19-2019 BOARD OF HEALTH Application for Septic Disposal System - Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER MA 01845 $ -Full Repair , $175.00 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 epair or replace an existing system component—What? to move your U 0 U (f cursor-do not use the return A. Facili Information key. - � �,,., v Address or of# rah City/Town oQ� �Nc N ZM 2.-*TYPE OF SJEPTIC SYSTEM*: ➢ ❑ Pump rVAravity(choose one) NFA ***If purr s stem, a ach copy of electrical permit to application`** ➢ onventional 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) ➢ ❑ Pressure Dosed (D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes oZK, 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) What is the Make? What is the Model? 2. Owner Information FW77 L_GEthM N me Address(if different from above) City/Town State Zip Code mail address Teleph ne Number 3. Installer Information Name rName of Company r)L u G J� Address n _ /l L y',an T/elcl �'�c� �l9 L�V City/Town State Zip Code Ce`., Sdj�-®7.� G-- ��.35 Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 `. y Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $ 00 -Full Repair $175.00 -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. I understand, at until a final Certificate of Compliance has been issued by this r of Health . to ed system is not approved. ame Date Applic on A By: (Board of Health Representative) c ( I (i Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes_ No r 2. Project Manager Obligation Form Attached? Yes No 3. Pump 3vstem? If so,Attach cov ofElectrical Permit Yeses No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval all a erwork received? YeJ PP 1� l� Missing.• 1 5. Foundation As-Built?(new construction only): Yeses No� (Same scale as approved plan) l 6. Floor Plans?(new construction only): Yqs o 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: 7.5 (Address of septic system) For plans by (Engineer) Relative to the application of (Installer's name And dated (Original ate Dated (01 o av, ate With revisions dated a..ast 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 (P) 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: bealthdept citowtiofriorthandover.eom) 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 b3�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: 7 (foday's Date) (Name _,Ile— tint are—S.tgnc Mp OTN V 7 ✓' \� o . 1410 O D Town of North Andover HEALTH DEPARTMENT ,sSACMU4t� CHECK#: ,? DATE: LOCATION: 7S5 H/O NAME: CONTRACTOR NAME: T�;�-7 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: bo�4 ❑ Septic-Soil Testing �' / k $ ❑ Septic-Design Approval )0 � $ 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