HomeMy WebLinkAboutHealth Permit # 10/20/2015 I
Application for epti spo 1 Svstem 1 r
a. TODAY S DATE
Construction ermit F
NORTH ` MA 01845 ��z5.oa-®mpoine tr
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 c.7
to move your ErIkepair or replace an existing system component—What.
cursor-do not
use the return A. Facility Information
key. l /i4 J-A.1
Address or apt#
City/Town N:
' 2.-*TYPE OF SEPT! SYSTEM*:
A ❑ Pump Q,aravity(choose one) � c," 2
***!f pump system, attach copy of electrical permit to application**'
➢ onventional System (pipe and stone system) NORTH
➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification Aftlkhhwooamystern.)
➢ ❑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)
whatis the Make? What is the ModcE�
2. Owner Information
Name /
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Co Rl X11 k: lT�"-Y' (`y�'� INC.
J14
11JCJV tt, Ib(,
Address E_ UiU1U .a
Cityrrown State Zip Code
Telephone Number(Cell Phone#if possible please)
a. Designeuinformation
Name Name of Company
Address
Cily/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
i
1
11 0, AppiI.ea or Septic Disposal .S.ystem -1-5- =
. �r �:�+ •:1;+oG . ... . TODAY'S DATE .
AGonstruc�t!on -Perrrrit = TOE. OF
ORTH AND b i 1VIA 01845 $250.00- om Repair
•x f
`125.00.•Component
4AC14USE`'
PAG2F2
A. Facility,Information continued....
5. Type-of Buildin esidential 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
North Andover, and not to place the system In operation until a Certificate of Compliance has
been Issue y this Board of Health.
Nam Date
lication Appr67d `�' Baard df Health Representative)
Date
Application Disapproved,for the following reasons:"
For Office Use Oniv.
I -Fee Attacbcd?: Yes No
2, Prolectl�"oger ObYgation Fotm Attacbed� Y d? Na '
31: Lu= s� tem &VO).Attach LAY cttical Pcrmr't`' Yes® ' No
4. FOUndadwAs B. ' ?brie construction,ronly)r -Yes No
(Same scale as toyed plan)
5. Floor Plans?(Mhe. coristru on'only): 'Yes® No
3,
AppICC tldn'fior•p(spOSai.Systbth.:iD trocfi�ii Permft' Rage 2 of 2
�-.• .ter
1
r -
As theNqtthAndoverMc=ed&uuJla fajr tie• cptO f6M6-aeptIc W ,'fft th p st:
(Ad4stu efsVe wet=) F'ot pUto by
a � ,�e
Rtlatva �tbc.ippt�d�of 4;
� .,� .
(iiai ■ A
�C lsd dittdd
a
Ihtted
{i�st sed date)
I mWeAtand the following 01192dons:fax Mausg'emcttt ofOie project:
• mcfBosrd of�eatith
1. Aa the fat I aus.abligatasi tip►abtAia AIlpe�str ep'provod g1L4t to .
�pedatttIqg sny-work an R kItr,.IM=hwetbr, MIM p. Est . a ►WCSr fs
2. As t}ic 3aktalter-.I,,=w vwai*v aay and sI1'# Vudw& I£ha;nea+a ve, cotttraetcK paeajectmxWVr,or any
othupenan nat mt#oeh ftd whh my maaxpssy gi a-an w�°n sad the syeteia is not seedy,then
3temtbtCG'a�itf.hra.s�pl�tbie. .
4 Ae x hsrve ttetty arc> x� pi to the.ap �e ittapGCt�oA 93
m b
t.• :d:: .s t �I" `# p - � �c 3s a~`?�ct�iin3ngi1,vctr
be y i*t =ftriii-M Wf await aft dc(culdt bane to be puvb t:••
b, ttti t r ;drx ap
for Okv&tiaras; .etc.
el
As t o orbit (or esl tix y from the es�tgiaars must
-be t ibudt6ed•ixi 1tc Bdtttd'a£Heattlbnmt: `�neti�tict peat a.time,'Inet�Itce itaust
be pzes�t ftxr tl*,kVecdeitt, •Vtb r triCAt�v4ttc, afi be to*ad Able to
cause p.txiar1c iti:att.,
C. v �ttlr tunst�;gtxe '' a►btticdina raaapltte: InstmAcr Baca stat
wet
4. As-the stet IM1I yntii�dut only IMF Ot&=ft • "W&O W ava")ind I At i•.t ed
• �ba complete��aat�lsttizatt of thae syste�i, � �#tib.: x f£oati�sattrllatFon:' .
'S.r ;Ah�� e�•Y uicter�tr�nad cI a���a• 3 dt '��•p ce:'r►f�� wring couat;+ac�na•
b
A: De at�O.ditLcat,tltap�e+s�re1'e1ew,atlamrc�ftlie aurtJ9vL+csaeAe„fieat'
a AV aftheawd&nds4ftvIv fro wed • - f:'
. � F�as ltnarpeatfas rbpBo�!'at.�5Te�5art'�orco�etsPdr� • • ' . '
d lamlg Ma daft 6fmnk D-VOjq fn 's,SWDIr aWt,PUMP dwftbff..rd , WtJotbcr .
b. A t• In ,dCi3l fi�1 j t i.Of j $t16 h {#.�i�._ � ll�kf Hive xni=at er ffic
IWO ,.
Unden.lpffil UMM4$lptiC. (r Iyalte
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Map-Block-Lot
Commonwealth of Massachusetts 107.A0044
r
��. BOARD OF HEALTH Permit No
• BHP-2015-0885
North Andover --------- ------------
FEE
P.I. --_----- $125.00
F.I. -----_
--.------------------
DISPOSAL K N UION PERMIT
Bateson Ent ------
Permission is hereby granted __.__._--_--
to(Repair)an Individual Sewage Disposal System.
at No 12 FARNUM STREET ----
__ 2o,2ols
- ._
___
as shown.on the application for Disposal.Works Construction.Permit No BHP 2015 YDa �
Issued On: Oct-20-2015 a BOARD OF HEALTH
— -- Map-Block-Lot
't Commonwealth of Massachusetts 107.A0044
B RD OF H LTH
orth And v r
C TIF"IC E OF MPL A CE
THIS IS C RTIFY,Th the ndividual ewag Disposal yste (Repair)
ates n En - ------ ------ --- ------- -
-------- -------
- staller
at No 1 FA M TREE _ --- ----- ------- ------ ------------
- -
has bee stalled in acc rdance with provisions o 'ITLE 5 of the e Environmen I ode as descri d'n the
application for Disp s Works Construction Permit No. BHP-2015-088 Dated -Octo er 20,_2015--_
-------------- -------------
Printed On: Oct-20-2015 BOARD OF HEALTH
---- ------------
Map-Block-Lot
Commonwealth of Massachusetts 107.A0044
lall%ll/,, % ----------
BOARD OF HEALTH Permit No
` BHP-2015-0885
North Andover
FEE
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Bateson Ent -------------
Permission is hereby granted --- ___-- - - -
to(Repair)an Individual Sewage Disposal System.
at No 12 FARNUM STREET --------------------------------------
----- --------
-------
as shown on the application for Disposal Works Construction Permit No. BHP-201 5,-088 4ted Odtabef 20,2015
Issued On: Oct-20-2015 BOARD OF HEALTH