HomeMy WebLinkAboutHealth Permit # 8/31/2015 alb Commonwealth of Massachusetts Map-Block-Lot
f 106.00050
BOARD OF HEALTH
• Permit No
North Andover -BHP-2015-03
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P.I. FEE
F.I. $250.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Robert Daigle______________________ ___
to(Construct)an Individual Sewage Disposal System.
at No 29 GRANVIILLE LANE
as shown on the application for Disposal Works Construction Permit No. BHP 2015-0 6 Dated August 31,2015
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Issued On:Aug-31-2015 BOARD OF HEALTH
1
„ , � . Application for Septic Disposal System
°1° TODAY'S ATE
Construction Permit - TOWN OF
250.0 Full Repair
NORTH ANDOVER, MA 01845 $1MA6 -Component
Important: ApolicatloVls hereby made fora permit to:
When filling out El 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 El Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
Y //�� /{
Address or Lot#
Vii/ ,141 6&f '°
City/Town
2.-*TYPE OF SEP,,TIC 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)
A ❑ 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)
Whatis the Make? Whatis the Model? � "['"
2. Owner Information � �: .:y d� � s,
)(9
Name `tl"(:Ar"Id�hI)III P,�r(7�f i K..(f AI',,(I WER
Address(if different from above)
City/Town State Zip Code
Email address Te ep hone Number
3. Installer Information
Name Name of Company
i cyl Ile t�rC
Address
City/Town St to a , Zip Code
Telephone Num er(Ce Phone#if possible please)
4. Designer Information
Name j Name oLCampaRy.
Address
fi t. 44<-
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
i
Application for Septic Disposal System TODAY'SDA'E
Construction Permit — TOWN OF i
NORTH ANDOVER, MA 01845 $250.00-Full Repair
$125.00 -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 i talled system is not approved,
f .
Name Date
Ap i tson pproved y',( 9f.Healt Rdpi6sentative)
V da
N 'me Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Project Manager Obligation Form Attached? Yes No
3. Pump System? If so,Attach copy ofElecttrcal Permit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Revieived approvalletter, all papetivotk received. Yes No
Missing:
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
G. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
II
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property u1:
(Address"[oq?6zoT,ietyi) For plans 6T d04 llff)'�IV41
Relative m the application of
And dated
Dated
With revisions dated
I understand the following obligations for management of this project:
1. }\o the installer,Iuuzobbgutod1oobtoinoUpermiteuuJ8ouz6oEI{cubbopprovrdo|uoo priot to
performing any work oous it
o. I must have the approved plans and the permit on site when any work is
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 ozy company schedules xuiuupocduuun6d6eaystcnzimootrcudv t6co
item three shall bcapplicable.
3. Ao the installer,lxou required tobuvetbcucceseuq/nro/kconupleuoGpziortod6oupplicublriuspectiooauo
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Tide 5 and the Board of Health RegWations mg�result in a $50.00 fine being levied against me and/o
my company.
u. Bottom of Bed—GeuerxDy, thioiat6o8cwt(1") ioupeodounoleaxdzeceiaxcotxiningnmDnhic6
should be Juoe 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 nf verbal(}K /oz e-mail to: 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 upump system, all electrical work must be ready and able to �
cause pump Ln work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have toboou-sito.
4. Aa the installer, I understand that only I may perform the work(o/6r than simple excavation)and Imozrequired
to complete the installation of the system identified in the attached application for installation. I further
understand that work done b)�others unlicensed to install septic sj�stems 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, sigLiificant fines to all persons involved are also possible.
5. .ix the installer,I understand that I must 6c on-site during the performance of the following construction
steps:
w. Determination /hu/ t6xJ0mopxrvlevati*n of the excavation has been rraxhxw(
b. Inspection of the /wwd and stow, to be used.
c. Final inspection by Board *fHealth staff orconsultant.
uC Installation of tank, D-Bo»� 2h6«x4 stone, vxwt,2ywmfi chamber, retaining wall and other
xw*vpomxwts.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
a1212roved 121ans. No instructions by the homeowner. general contractor, or any other persons shall absolve
me of this obligation.
'( 4Undersigned Licensed Septic Installer: (Tod, Date)