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Home My WebLink AboutFull Repair - Septic Pumping Slip - 997 DALE STREET 8/14/2019 Commonwealth of Massachusetts Map-Block-Lot 104.A0099 ----------------------- BOARD OF HEALTH Permit No North Andover BHP-2019-0189 ----P-20-9-01 ------ FEE $350.00 -------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter Breen --_------------- to(Construct)an Individual Sewage Disposal System. at No -997 DALE STREET ------------ as shown on the application for Disposal Works Construction Permit No. BHP-20 -0 9 Date us 4,2 - ------------ -------- Issued On:Aug-14-2019 BOARD OF HEALTH 19 c Commonwealth of Massachusetts Map-Block-Lot 104.A0009 ----------------------- BOARD OF HEALTH Permit No North Andover -BHP-2019--0189------------- -- ------ P.I. FEE F.I. $350.00 --------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter Breen - --sue --- ------ to(Construct)an Individual Sewage Disposal System. [ �a at No 997 DALE STREET ` '-— as shown on the application for Disposal Works Construction Permit No. BHP-2019-0 89 Dat t 14,2019 Issued On:Aug-14-2019 BOARb OF HEALTH Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-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* REG only the tab key ElWh [� Repair or replace an existing system component— a? to move your f. 4 2o1C� cursor-do not w use the return A. Facility Informati n _ , NQO key. ? (2, �/�,�/� J ��, N�F��o RZMENT Address or Lot# H�1. 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) .. -➢-`-u_t'fe��G fe D.osed�(D=Box-Pres-eni)-0`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 brand of filter before DWC issuance) Mat is the Make? Whatis the Model. 2. Owner Information _4n; 616 iA17 x. a �� XT Name 997 Am,& Sirze-/ Add'�re��(if different from bove) City/Town State Zip Code Email address Telephone Number 3. Installer Information 1,31:�,el) A Name Name of Company 770 AOX ror 54 Address City/Town � State Zip Code /'�u/c177o y 'i'7(9 - o/87 -77 7c/ Telephone Number(Cell Phone#if possible please) 4. Designer Information __Z_Aae�]�O ��!�e /_ Name Name of Company S C? �11 �in 5 It' 50 /C) / Address CitylTown State Zip Code T 9-78 - 539 80 ,38 oe - sob-8Y3- Telephone Number(Best#to Reach) 0 1 4 Application for Disposal System Construction Permit-Page 1 of 2 / // Application for Septic Disposal System TODAY'SDATE Construction Permit - TOWN OF $350.00-Full Repair NORTH ANDOVER, MA 01845 $175.00-Component 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. I understand that until a final Certificate of Compliance has been issued by this Board of Health,the installed system is not approved Name Date T Applic. ' pp ve B . (Board of Health Representative Name Date Application Disapproved for the following reasons: For Office Use Only: / l Fee Attached. Yes✓ No I'to"ectMan et Oh . adon Fam Attached? Yes No 2 l 3. Pump Svsemm? Ifso,Attach copy ofElecttical Permit Yes No Applicant.teceived copy of "Electricallnspectron Notes for Septic Systems" Yes No Handout? 4. Reviewedapptovallettet,allpapetwotlrtecaived-P Yes No Missing.- 5. Foundadon As-Bzult?(new construction only): Yes No� (Same scale as approved plan) 6. FlootP]2.ns?(new construction only): Yes No!� 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: 79 (Address of septic system) For plans by (Engineer) Relative to the application of A 7`�� .e/7 (Installer's Wme) And dated 7 ;9_020 8 to Dated o asate With revisions dated -? �2-1,!AQ (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 work7is 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(V5 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 OIL(or e-mail to:healthdept@northandove.tma.gov)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 offfealth 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 pet the approved plans No instructions by the homeowner,general contractor, or any other persons shall absolve me of this objigagtion. Undersigned Licensed Septic Installer: (Todafs Date) ✓`��` l� p AJ ,er /6/.ems (Name—Print) ame—Signed7 Of NORT ft�h 870 F 2 i • . Town of North Andover HEALTH DEPARTMENT ,sSACHU`��S 7 CHECK#: DATE: L00 LOCATION: ? 9 7 / H/O NAME: Qr CONTRACTOR NAME: 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 $ i ❑ Sun tanning $ j ❑ Swimming Pool $ j ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ 9 i ❑ Well Construction $ SEPTIC Systems: j ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ Septic Disposal Works Construction(DWC) $ 0 !❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ f i Healt Initials White-Applicant Yellow-Health Pink-Treasurer