HomeMy WebLinkAboutDWC - Permits - 55 WINTERGREEN DRIVE 9/23/2019 wvmmumm�w.wwmoo� imi
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Commonwealth of Massachusetts
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BOARD OF HEALTH
i cmit No
BHP-21 9221
North An+ ve"
FEE"'
$1 5,00
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�.DISPOSAL WORKS CONSTRUCTION
'wERMIT
Perrmssion is hereby granted
to(Construct)an,Individual Sewage Di,sposal, System.
at No 55 WINTERGREEN IVY=
shownas the application for Disposal Works � tr��tcr Permit 0 t 31
2019
_.
�Ipyypk ' s i
Ucafinon forAsm i Septi e' � Is osai System
Construction Permit � TO i OF �350.00 Full Repair"
d
NORTH ANDOVER, $175.00 C m�Ip or r t
Important Application Is hereby made for a ermit too.
Where filling:out Construct a new ►n-ante sewage disposal system*
forms on the
computer,use Repair or replace an existing on-site sewage disposal system*
only the tab key
BoAepato move your
Ir r replace,ga r existingsystem cow onent— �aat "
cursor do not �I
use the return A ac I!"IInformation
Address or Lot#
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2.00;*TYPE OF SEP1T1f,*-WSTEM
E] Pump ravity(choose one)
***If pump system,attach copy of electficalpermit to application *
Conventional System (pipe and soya system)
Infiltrator or Blodiffuser(Gravel-Less)(,attach a copy of o r certification o install this type of syste .,
l Pressure Distribution S.A.S.(No D-Box)
Pressure Dosed(D-Box Present)S.A.S.
Does the system require an,effluent filter? Yes N
f yes, Foes plan specify make and modelf filter?r? YES- no further into. needed)
N �(installer must specify brand of filter before DEC issuance)
What IS die e? at.'s the oriel?
2. nee Information
_ L
Name
6Address(if different from e
Cityrrown State Zip Code
. mail�~aura.ss�..w_.._..�_.__�_.m__�_._a�_�_..�...�.o_..�. Telephone Number
Name of CU%ids
Name SrONSt�TERPA[S--,E-S, INC*
3. Installer Information
Address
M]DOVER, 01810
City/Town State Zip Code
Telephone lumber(Cell phone#if,possible please)
41. Designer Information
1a-me Name of Company
r
a
i
City/Town Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Pen-nit-Page'I of 2
N
A 1212"0 cation for Septic DID osal t m
,
TODAY'S CRATE
Construction Permit - TOWN OF
$350.00 Full Repair
NORTH AND OVER2.1.11111111INU 01845 $175.00 Component
PAGE 21 OF
A. Faclnl*l!y Information continued.U..
5. Type of Bu IWinWesidential Dwelling orDCommercial
B. Agreement
The undersigned agrees Co ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions offide 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town o
North Andover. i understand that until a final Certificate of Compliance has been leant by
is Board of H ,the installed system is not approved
Name Date
olelollo
Ord
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(Board"Po � wr� �r ,��i��;
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Date
Wu
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Application Disapproved for the following reasons-
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For Office Use' On ,-. �
1. Fee Attached? Yet01
2 Project Manager Obi` on Fonn Attached? Yes 1
3. Pum stem? If so,Attach Co ofEleettical Permit
Applicant received copy oir
"E ec ika1 Inspection Notes for Septic Systems Ye
H.,wdu
P
9 Foundation -Built?(new consttuction Daly). Yes 0
(same,kale as appro vedpan
Floor s?(newconstruction only). Yes
,a
Application for Disposal System Construction Pen-nit 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:
.,off„ w
VV v
(r,Wdress,of septic system) For plans by
1-Al ine
Relative to the application of
And dated
( Sr'Aller'S
Dated C�'"".
T 7 ra T-1 With revisions dated
j, re iised date)
I understand the foHON *Mg o'bfigations for management of this project.-
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans rear to
performing any work on a site. I Must have�e_a�rov�ed�Ian�sa�nd_theer�rnit_on sitew�hen are- wprk is
being don,.-..
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 reqm*red to have the necessary work completed prior to the apphcable inspections as
indicated below. I undgrstand that reauesting an-inst)ection-3 without cow n of the items in acc rdance
with Title 5 and the Board of Health ReWAations,may,result in a$50.00 fine being levied against me an&or
my cow pmy.,
;r-- X
a. Bottom of Be —uenerally. 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-ma ,cr from
il to: twall d n.co the e gineer 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. F M* al Gra —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 unhceased to install,se tic-5,-v ate ms in North Andover can constitute
reasons for denial of the system and car revocation or sup ension of my license to on,erate in the Town of
North Andoversitq_�ficant fines to all ersons involved are also,nossible.
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. Ins pection of the sand and stone to be msed.
c. Final *in s pection by Board of Healtb staff or consm/tant.
d. Installation of tank, D-Box, .pip es, stone, vent, pmmp ebamber, retaining wall and other
comPonents.
6. As the installer..1 understand that I am soldy rep nonsible for the installation of th.e---system asPer the
approy ans. oeneral contractor or an other mrsons shall absolve
gd pi— _Q.instructions by the homeowner".1
me of this obi egtion.
Undersigned Licensed Septic Installer:
09 j
(Nanae-- 11'rn',Alt) 4e (Name Signed)
1
F
8748
110
Town of North Andover
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HEALTH DEPARTMENT
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0 Animal
0 Body Art Establishment $
Body Art Practitioner
DumpIster
0 Food Service-Type:
5
0 Funeral Directors
• Massage Establishment
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• Massage Practice
offal• (Septic)Hauler'
• RecreationalCamp
• Sun tanning
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• Swimming
Pool
Tobacco
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0, TrasIVSolid Waste Hauler
Well Construction
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Septic Soil Testingr
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Septic De; Approval Iwo,
Septic Disposal Works Construction
Septic Disposal work installers311,
Title 5 Inspector
Tide 5 Report
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0 Other. (Indicate),
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