HomeMy WebLinkAboutHealth Permit # 6/25/2014 • Commonwealth of Massachusetts Map-Block-Lot
106.D0065
BOARD OF HEALTH Permit --
North Andover BHP-2014-0676
------------------P.I.
_ _ FEE
F.I. $250.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
to(Construct)an Individual Sewage Disposal System.
at No 49 WINDSOR LANE
as shown on the application for Disposal Works Construction Permit No_ BI-11-2014-067 Dated e 25,2014
----------
Issued On: Jun-25-2014
BOARD OF HEALTH
° Application for Septic Disposal %Lstem
,
TODAY'S DATE
Construction Permit - TOWN OF
NOR 0184 $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 epair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information �.�
, 9
�
key.
n
Ie`n�ca _
Address or Lot#
City/Town � E.r kr�t I `I wd l/i�r c4 fF
2.- TY PE OF SEPTJC SYSTEM*: C
➢ ❑ Pump [ErGravity(choose one)
`1f pump sy m, attach 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 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)
What is the Make? [What is the Model?
2. Owner Information
Name
Address(if different f from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of o
/f /pro ,.�,,� Ill E�EPPPIS ,INC.
Address ANDOVER,MA 01810
City/Town State Zip Code
/L .. �,
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address y y
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
G 4a :T 1yo pplicati'oh.. r Septic i pc. I :' t d
,�_ ..e, °•:• �� . TODAY'S DATE
` a Gonstruction Per it = TOWN OF
* . *.. :
♦tiY' `ORT ANDOVER, MA 01845 $.ZSO.00-Pull Repair
. •$125.00.-Component
1SSACHUSk
PAGE 2 OF 2
A, Facility•Informatio.n continued....
5. Type-of Building: esidential Dwelling or ElOommercial
B. Agreement
The underslgned agrees to.ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been Issued PY this Board of Health.
•
Time Date
pile 171 Appro. �B d of Health Representative)
w '
Name Date <
Application Disapproved,for the following reasons:
For Office Use Only:
1 FeeAttachedP: Yes_ No
2., ProjectMariager Oblrgatiorn Form Attached? Yes No '
3.: Primp 3 — Ifsoj Attach copy of.Electrrcal Permit:-..' Yes NO
4, FoundatioaAs-Built.?(new construction ronly), Yeq No
(Same scale as approyed plan)
5. FloorPlans?(new construction only): Nc
AppiTcatl®n'f�r•pisp0$al Systeiii: onstructioh Permft Page 2 Of 2
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