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Home My WebLink AboutHealth Permit # 10/29/2010 1, I Application for Septic Disposal System, JJ O� TODAY'S DATE Construction Permit - TOWN OF NORTH DOVER, MA 01845 $250.00-Full Repair $125.00 -Component 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 MiRepair or replace an existing on-site sewage disposal system* only the tab key to move your epair or replace an existing system component—What? (Is"r, cursor-do not use the return A. Faciilliity Information `/ key. � 1 Address or Lot# Q be t"T�- City/Town 2.-*TYPE OF SEP C SYSTEM*: ➢ ❑ Pump FGravity(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) ➢ ❑ 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? 1V1jat is the Model. 2. Owner Information j it . Name t ✓✓ ei " Address(if different from above) jyj�City/Town State Zip Code Email address Telephone Number 3. Installer Information Name Name of Company 0'_h 1 r+1 Address City/Town State � �»� Zip C,eGie� Telephone Number(Cell Phone#if p(("o�isible 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 1 Application for Septic Disposal System, TODAY'S DATE Construction Permit — TOWN OF NORTH ANDOVER., M.A. 01845 $125.00 -Comp enent I l i PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Vesidential 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 Ando ve . I u derstand that until a final Certificate of Compliance has been issued by th' ar of a h, the installed system is not approved. ,. e Date q(B A ' atip n pproved d of th°Representative ', 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 ofEleco cal Permit Yes No Applicant received copy of "ElectricalInspection Notes for Septic Systems" Yes No Handout? 4. Revietived approvalletter, all papettivork receiveda Yes No Missing- 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 t As the North Andover licensed installer for the construction for the septic system for the property at: k s ._ ' (Adclt-ess of septic system) For plans by Relative to the application of V g P n Z, (Installer's, n anie) And dated �_ri�;ans� date) Dated Zq /( _,s date) With revisions dated (Last revised dace) 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 ip.ior 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 company. 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 OIL (or 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 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 si»aple 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 121ans. No instructions by h ho eo er gen&ral contractor, or any other persons shall absolve me of this obligation. .0 Undersigned Licensed Septic Installer: t � �w�, � �, lay'• L7at:e) c �Gk 1J io`ViAJ Natnne-- Print ( at — .ngnec. . UD Commonwealth of Massachusetts Map-Block-Lot 104.00162 Penn- BOARD OF HEALTH • Permit No North Andover BHP-2015-0880 ------- ------- -- P.I. FEE F.I. $125.00 DISPOSAL N T LJ '°TION PERMIT Permission is hereby granted John-DiVincenzo to(Repair)an Individual Sewage Disposal System. at No 759 DALE STREET as shown on the application for Disposal Works Construction Permit No. BHP-2015-088 Dated October 09,2015 ------ -nAFHzALmH- Issued On: Oct-09-2015 4 � • F+T';e°' ' , Commonwealth of Massachusetts Map-Block-Lot • 104.00162 BOA OF HEALTH No h ndover CE T ICA"TE OMPLI IBC S IS TO CE TIFY,Th the Individ al Sewa Disposal Sys m (Repair) by ohn-Di- - -incenz- ----- ----- -- - ---- -------- ------------- --------------------------- ------------- --------------- ------------- --- ----------------------- ------ ---------------- Inst Her at No 7 D E A STREE has been installe ' accordance with the provisions of TITL f the State Envir•o tal Code as described in the application for Disposal Works Construction Permit No. BHP-2015-089 Dated-_October-09,2015--- ---------------------------------------------- Printed On: Oct-09-2015 BOARD OF HEALTH • tom'}°� 4 Commonwealth of Massachusetts Map-Block-Lot • 104.00162 -Permit - BOARD OF HEALTH • Permit No .North Andover BHP-2015-0880 FEE $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John D1Vincenzo ---------------------------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 759 DALE STREET as shown on the application for Disposal Works Construction Permit No. BHP-2015-088 Dated October 09,2015 ,2 --- ------- -- ---- ---------- Issued On: Oct-09-2015 BOARD'OF HEALTH