HomeMy WebLinkAboutDWC permit - dbox 10/18/05 - Permits - 261 REA STREET 2/24/2020 - - - -
Nd"'" Commonwealth of Massachusetts Map-Block-Lot
038.0-0032-
3? °; Board of Health Permit No
North Andover
BHP-2005-0576
• �•
' ve
P.I. FEE
�'Fs sts�e F.I. $125.00
�t HU
Disposal Works Construction Permit
Permission is hereby granted Mike Reilly
to(Repair-D-BOX ONLY)an Individual Sewage Disposal System.
at No 261 REA STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2005-057 Dated October 19,2005
Issued On: Oct-19-2005 Board of Health
....................--
"°R'" Application for Septic Disposal System
TODAY'S DATE'
M,Construction Permit - TOWN OF
w
NORTH ANDOVER, MA 01845 $ 250,00, Full Repair
125.00 -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 �epair or replace an existing system component
cursor-do not
use the return key. A. Facility Information
Address or Lot#
/IMor
Prim City/Town
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)
❑ 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) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
` �1 y
Name
Address(if different from above)
Cityrrown State Zip Code
Telephone Number
3. Installer Information
Name) J_ Name of Company
Zb& � --
Address
Ageggj lr
Cityrrown State Zip Code
9'7$'— 37�— yp//
Telephone Number(Cell Phone#if possible please)
a. Designer Information N4
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
NORTh Application for Septic Disposal System /o--, 8— o57
�-Construction Permit - TOWN OF TODAY'S DATE
X Y'
$ 250.00- Full Repair
NORTH ANDOVE R,MA 01845 $125.00 - Component
SSACHUSF
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: 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, and not to place the system in operation until a Certificate of Compliance has
been issued b.V this Board of Health.
ZvoS
Name Date
Applicatio pproved By: ( td of Health Representative)
N e Date
Application Disapproved for the following reasons:
For Office Use Only: /
1. Fee Attached? Yes I/ No
2. Project Manager Obligation Form Attached? Yes_ No iww
3. Pump So sy tem? If so, Attach cop.y of Electrical Permit YesAl� No
4. Foundation As-Built? (new construction ronly): Yes No
(Same scale as appromd plan)
5. Floor Plans? (new construction only): Yes No
1
i Application for Disposal System Construction Permit•Page 2 of 2
Tow.-i of i;orth Andover
d
Health Department Date:
Location:
(Indicate Address, if Residential,_or Name of Business)
i
Check#:
Type of Permit or License: (Circle)
➢ Animal $
➢ Dumpster $
➢ Food Service-Type.-
Funeral Directors $
➢ Massage Establishment $
➢ Massage Practice $
➢ Offal(Septic)Hauler $
➢ Recreational Camp $
➢ SEPTIC PERMITS:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
_❑ -Septic Disposal Works Construction(DWC)$�
❑ Septic Disposal Works Installers(DWI) $
➢ Sun tanning $
➢ Swimming Pool $
➢ Tobacco $
➢ TrashlSolid Waste Hauler $
➢ Well Construction $
➢ OTHER:(Indicate)
3
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer