HomeMy WebLinkAboutApplication - 73 FARNUM STREET 10/5/2015 ff
Application for ti_�. i o 1 t �
TODAY'S DATE
_
Construction;Perrn it — TOWN OF
2 - 1 $725.`00-comRepair
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 j� �mg
to move your epair or replace an existing system component—What.? =� '
cursor-do not L T
use the return A. Facility Information
key.
Address or Lot#
hrf r
� ✓ d �✓
City/Town
2.-*TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump ravity(choose one) T(
* if pump syste , 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.)
A ❑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 D WC issuance)
What is the Maker' What is the ModehI
2. Owner Information
Name
Address(if different from above)
City/Town State Zip Code
'`7 C,, — V
Telephone Number
3. Installer Information
Name Name of Co an
//4- e A ,-,Ofq ENTERPRISES, INC.
I1 7"RG-1lrL.�1 •,...
Address ANDOVER MA 0-18-1 o
Cityrrown State Zip Code
✓ 8- 4—7,
Telephone Number(Cell Phone#if possible please)
4. Designer information
Name Name of Company
Address
CityiTown State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
MdwrH
c�4d®•,,,a
pplic , i t .. r p is i PO.'s t
�� `��
a Construction -Permit T ToDArs D E
RTH ' MA 01.845 $.250.66-Full Repair
sgCHO $125.00,-Component
PAGE 2OF2
A. Facility,Inf6rmation continued....
5. TWe'of Buiiding: C36sidential Dwelling or®Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-slte sewage disposal system In accordance with the provlslons of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
r, North Andover, and not to place the system lri operation until a Certificate of Compliance has
been Issue y this Board of Health.
Name Date
p � i
�a pprov y'..( oa d of Health Representative)
1 i A•
4 Date
Application Dlsapproved,for the following reasons:"
For Office Use OMv
1 ''Fee Attached? Yes
No_
2,• PtalectArg,62get Ohlrgatiors Form Attac6eda Yes
Attach Coy®ofElect�rl'Cal Arrmra deg No
4. FoucraGatr�r� urlt.?(flew Construction ron/y); Yes
(Same scale approved plan) NO—
r •
5. FloorPlans?(hew canstr tion oniy); Y.es
No •
APP,!4tf6n,fior•DIsNgat oyster t06nstracacih permIt:Rage 2 of 2
SFP `IC'S S 3'�I i '•x' P=MA
As tho-Nprth Andover3c=scd t xodjft fo)r Oft,tMXtMCOCA ft'the.e Wr syaterix for.the�pt4 Cettyae
to °f sqft fog? pUm by
Rehdvd to dt6 #fmd=of e
(h"dwo Oame) Abd dated
Dated C'
o : a'te')-- vet r'm�dated
(Lmt revised deter
I uaderatand the following Obligations for mmu,gement of jis pm-ect:
i. Aa theiastrllct I i+mm.vbligut�ed#a obddaallpet��ad'Boatd ot�Ie�lth nPpmvEdP,t�a�to -
�peei�iag aap.'morZc dn.a edte.•.
Mimi e.
. As die imtalkt�.I�z bi tt mu m turd i� upt ibw: T£baraec oo ct�t,project mgrs,ar anp
4erpenon ttat*uocfatcd with my c moq�•an ksp mdm and the Syrsteri:is nctnscdj that
, xtq too bscv�ee .
ituiu tee Ott - - ° tluAPPltObku a tans
filit film
is*fio#" pdatr+a�- s.: c srrct tg clr
. - tad b�di5n�:i�i�• ..�wat��ii . _"��at�ii�pact�os��t e��ies•not bave to btr p�ffcrit:
b. — ttlUrtihep, tm far ckv�►Ziona,�t ,ct�c.
o 'mid OIC"(ar e•m�l from the erfghiar,•r trrast
ba tttibmittied trt tc-� ofllsattt�,s L W IWAAANN t dine,'X=dll&i3 u
bept~estst&r fl*.fngp . Vat* .4 A AtO& h � be rcmdy and able to
• 'r �v�p•tti�ovotktitid�lat��o . . ,. - • -
• .' c. '�,—�dt�t�i]Iermecatroque� t regectroaarhe�i�l$r�ding�scn�pl� Iusta3krdor•��tot
• have#o ba tiu��te.' .' .• '•
4. As-the imstslie 'I that only+I y pt $se k'�it6irt6a�r doo feu)Md I AM t'egqued
. • tea aos:lplete tJiti•�asi�ttitist of the spatr.:giit��#li��spplt`�a�o�'�r•itiata�llatlaa'j
zs— t :s> t' a Ind °afN 'ta Ero ;i ►t�;
5.. Ab k itho conitracfitm,
� •r•
dad LI7fE�Ott o&
b. 4 l�tJ�arf�rfit"i�ead grad aCxri U owd ,
co 0 Pms llaarpeaoabpBoatntal. er.�lt�rdt7l�`'OtG'O�B #,•
d I�del�tYc afmak,l�- a�g n „FmQe,trout, ,ceu4ft wgggv f other -
cv�mpaaeatl�
tS.
As the in ' er' ud f T' Y��frir fietsIIadnr,..f}���p�����
me
Uailtopa UC4 wd SOPdC.UWAfter. '
_ (r Q '. . � .
