Loading...
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 ° , i i t 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