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Home My WebLink AboutMiscellaneous - 205 CAMPBELL ROAD 10/19/2015 (3) i Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE NORTH DOVER, A 01845 $125.®o=c mpo ent 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 sys m* only the tab key to move your epair or replace an existing system component—What. PIV,. cursor-do not use the return A. Fac Iity Infor atio ,) key. ° ° :3 Address or Lot# tab - )Val -e C City/Town 2.- 'TYPE OF SEP IC SYSTEM*: A ❑ Pump Gravity(choose one) ***If pump sy , attach copy of electrical permit to application*** y 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? lfbat is the Model? 2. Owner Information •/� / ,� Name Address(if different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information �;ty k Aj em-W"/ N' .5&-0 - :. Name Name of Company Addres ellpec"Iel, City/Town St to Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 I i i Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S DATE NORTH DOVER, A 01845 $255.0—Full Repair $125.00 -Component t PAGE 2OF2 i A. Facility Information continued.... 5. T yp e of Building: esidential 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 Enviro mental Code, as well as he Local Subsurface Disposal Regulations for the Town of Nort An ove .f1h derstan at until a final Certificate of Compliance has been issued by this o d of the i tailed system is not approved. 1 N Dat Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Ohligation Form Attached. Yes No 3. Pump S sy tem? If so,Attach copy of Electrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork receiveda Yes No M1SSln�;' 5. Foundation As-Built. (new construction only): Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit-Page 2 of 2 i SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North And ver licensed installer for the construction for the septic system for the property at: 4-- (,Address of septic System) For plans by (E.,"ngineer) Relative to the application of T6 l o L DWi/ice-k�s2i" (Installer's narne) And dated )rtgtn,,fl dare) Dated tr I (yoda)"s d,,ft) With revisions dated (Lao 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 p1lior to performing any work on a site. 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 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 co=an)L. a. Bottom of Bed—Generally, this is the first (1') 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-mail to: heattlidet)t(ii�,towii()fiic)rth,,itidc)ver.cLotii) 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 of Health 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 per the approved plans. No instructions by the laomeoNwer. general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: c(]a. s Date atxtc 7-ar Signied) Print) ® , I a I PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of® 7/9/201 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of o By: John DiVincenzo At: 205 Campbell Rd. Map 00 North Andover, MA 01 The Tssuanee of this certificate shall not be construed as a guarantee that the system will function satisfactorily. i Michele Grant � ) Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com i I North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 205 Campbell Rd. MAP: L OT: INSTALLER: John DiVincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box INSPECTION: , DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port i i ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMPCHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX F]"" „��,-Installed on stable stone base H-20 D-Box ❑ , Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets a, _.... Observed even distribution ❑ -.Speed,,levelers provided (not required) Schedule 40 PVC Pipe Comments: .....__......w.. ......................................................................... ................ AdOO .S. , 00.5ZTS aunOWV ............... u.�nqipT9[ 13stI :Aq pan!aoad ..... .................................. -----....... I£i�VT '.ON �oau0 ozuaau'A!([ 11110f ; :A 8 p!acl ....._..�IOZ'9Z unr t.,A :uO Ilnj u! P!cd --------------- ®c�u�.-. .. .. ................ ............ .�ieda luau o�°� :ON jdiaoa� :adAj aaJ i ££sT00°SIOZ-a ................................. .................................... :O un000d �aA®puV �jL�o�j i T�nV'API AO VOa 00'0TS0°S°T'TOOTOOT N :juauaadaO ........ g0ZO®Sm-d ®N 1!uaaad :ON aouaJaia� (TVO� Ijj9dti�VD SOZ 9£0000®5IOZ®M L............................ ............................................................................................................................................... • .,t T'� ��r$; Commonwealth of Massachusetts a Boo Lot BOARD OF HEALTH Permit No North Andover BHP-2015-0286 FEE $125.00 DISPOSAL WORKS CONSTRUCTION PERMI7C Permission is hereby granted John DiVincenzo to(Repair)an Individual Sewage Disposal System. at No 205 CAMPBELL ROAD ------------------------------------------------------------------------------------------------------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No. BHP-2015-028 Dated June 26,2015 i = ----- Issued On. Jun-26-2015 BOARD 0 F HEALTH