HomeMy WebLinkAboutHealth Permit # 10/27/2015 Commonwealth of Massachusetts Map-Block-Lot
038.00183
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BOARD OF HEALTH Peanit No
North Andover ---BHP-2015-0324-------------------
P.I. FEE
F.I. $125.00
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DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson -------------------------------------------------------------
- - -----------------------------
to(Repair)an Individual Sewage Disposal System.
at No 40 NORTH CROSSROAD 17
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as shown on the application for Disposal Works Construction Permit No. _13TAP-2015-032 Dated -July-3-0,2-01-5---------
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Issued On: Jul-30-2015 BOARD OF HEALTH
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-7
i
Application for Septic TODAY S D ATE
Construction Permit — TOWN OF
NORTH ANDOVER„ MA 01$45 25.00°-component
Important: Application is hereby made for a gennit 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
to move your ep ialr or replace an existing system component–What? 'c4L'- ?_
cursor-do not
use the return A. Facility Information RECEIVED
key.
6 Address or Lot#
City/Town
JiEAOi b W1k',RiI,At`N!
2.-*TYPE OF SEPM SYSTEM*:
➢ ❑ Pump ErGravity(choose one)
***If pump sys m, attach copy of electrical permit to application-
➢ anventional System (pipe and stone system)
➢ E] 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? What is theModelt
2. Owner Information
Name
i Zip Code 1 �
Address(if different f rom above)
City/Town State p
Telephone Number
3. installer Information
Name Name of Comp ny
f l d Af'q; Cam_ z� GN ENTEd-rr,1c-� �n
Address ARCILLFI
ANDOVER, MA C 161 o
State 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
�fdnv s1� eptic i pplip ti' . Or . 1 ..b ty .r. ...._.
p C.on trl.�ction -Permit ® 1 TODAY'S DATE
'`f"* ' O. �b OVER4 MA 01845 $.250.00-Full Repair
c►+us
CHUB $'125.00,-Component
s� ,
PAGE 2 OF 2
A. Facility•Information continued....
5. Type*of Building: esldentlal Dwelling or❑Cornmerciai
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, and not to place the system in operation until a Certificate of Compliance has
been Issued b this Board of Health.
Name772 Date
w
A li `ati n proved B
o
� � salt epresenfative)
Date
Application Disapproved.for the following reasons:
For Offi'6e Use Only`
1 "Fee Attached.' Yes No
2.- Pr01ectAf9fta9et M gatrorr Form Attacbed? Yes Na
31: Pum,�Svstem? If'sot Attach ca,�y ofElec %�alPetmit'•i 'es� ' ' ', No
4. Forzxrdatr'orrAs Bur'1't.?(new construction-ronly): Yes No
(Same scale as approyedplao)
5. F10orMws?(hew construction only). Yes
No
Appitcatldn'�or•plsppaal Systertt•:t onstructloh Penn-Page 2 of 2
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