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Home My WebLink AboutDWC Permit - Full Septic Repair - Permits - 1 PENNI LANE 11/20/2019 . ytsrr.eo, Commonwealth of Massachusetts Map-Block-Lot 107.D0057 BOARD OF HEALTH Permit No North Andover BHP-2019-0147 - ------------------ ---- P.I. FEE F.I. $350.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Dean Dynan i - -- --- . -------------------------- - ------------------------------------ to(Construct)an Individual Sewage Disposal System. at No 1 PENNI LANE -------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP- 0 0147 11,20 9 -- ----- - --- ----- ------------ -------- Issued On:Jun-11-2019 BOARD OF HEALTH Affibb Application for Septic Disposal System TODAY'S ATE Construction Permit — TOWN OF $350-00- NORTH ANDOVER, MN 01845 $175.00-Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* VED forms on the Pace, computer,use ElRepair or replace an existing on-site sewage disposal system* only the tab key to move your El Repair or replace an existing system component—What, ri►t�1 cursor-do not RrtH PNQtJVER use the return A. Facility Information pP Np �N1 key. /[/ Z ^e 10 ��H pPp,R�M Address or Lot# CitylTown 2.-*TYPE OF SEPTIC SYSTEM': ➢ ❑Pump ❑Gravity(choose one) `lf pumKE.nv�ntional tem attach copy of electrical permit to application*** ➢ System (pipe and stone system) ➢ nfiltrator or Biodiff use r(Gravel-Less) (Attach a copy of your certification to install this type of system.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) —ll-rFe�sure`u.osea-u-Box.r,resenr`-S-A-S.. ➢ 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 bra/ndd of filter before DWC issuance)) /�- What.&the Make? WhRtis the Model. r Dt—/ 2. Owner Information Name Address(if efferent from above) l 4^/1./ tG,,e CjtyTown State Zip Code le 6 cow► �/ 7 7� 7 ql �r Email address Telephone umber a. Installer Information Dext. "-4^ Name Name of Company (Address ,G City own State .// Zip Code Telephone Number(Ceff Phone#ifpossi e please) 4. Designer Information G 4VCA ZLI,]c Name 4Name of Company __llC/,, 1/ Address CityfTown State Zip Code Telephone umber(Best#to Reahh) Application for Disposal System Construction Permit•Page 1 of 2 Application for Septic Disposal System l l TODAY'S DAT Construction Permit — TOWN OF r0.00-Full Re air NORTH ANDOVER, MA 01845 $175.00- omponent PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: E]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 over. 1 understand that until a final Certificate of Compliance has been issued by thf oa of Health, i t fled system is not approved. Name Date Applic o A o ed By: (board of Health Represent"'ve Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes / No Z. ProjectManaget Obligation Form Attached. Yes i/ No 3. Pump S sy texas? Ifso,Attach copes ofElectzrcal Penzt Yes No AppAcant-receivedcopy,of "Electcrcal-inspecdan Notes for Septic Systems" Yes No Handout? 1 / 4 PP Reviewed a rowd letter,ad papet�wu&received? Yes✓ No Missing. 5. Foundation As-BuiltP(new construction only): Yes No (Same scale as approved plan). 6Floor Plans?(new construction only): Y — ° Application for Disposal System Construction Permit-Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the orth Andover licensed installer for the construction for the septic system for the property at: I z M.", 1!? (Address of septic system) For plans by (Engineer) Relative to the application of (Installer's name) And dated n ate Dated ate With revisions dated All i st eviA ate) 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(1s) 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@townofnorthandover.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. l Undersigned Licensed Septic Installer: (Today's Tate �/ ///(2 /10 l ame—Print) ` NORTH 8 6 V ,7 ° a • _ Town of North Andover HEALTH DEPARTMENT SA t� CHECK#: a2Y:, DATE: LOCATION: I H/O NAME: 150 A, ? CONTRACTOR NAME: &/ULn 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 $ L Septic Disposal Works Construction(DWC) $350 ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Ptrlth Agent Initials White-Applicant Yellow--Health Pink-Treasurer