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HomeMy WebLinkAboutHealth Permit # 11/16/2015 I 1 Commonwealth of Massachusetts Map-Block-Lot 107.A0241 ----------------------- BOARD OF HEALTH remittNo North Andover BHP-2015-0368 P.I. FEE F.I. $250.00 DISPOSAL K N T TI NI PERMIT Permission is hereby granted R©beet Daigle-----------------------------------------------------------I----------------------- to(Construct)an Individual Sewage Disposal System. atNo 101 SPRING HILL ROAD ------------------------------------------- .------ ---------------------------- _ ___pp_ _- -- Dated. -August ___-_ as shown on the application for Disposal Works Construction Permit No. BHP-2015 03,6 � -3-1,-2-01-5_ -- -- Issued On:Aug-31-2015 Dm"07 HEALTH i 1 i Application for Septic Disposal System � Construction Permit — TOWN F TODAY'S DATE NORTH ANDOVER, MA 01845 (21 3'.00 -Component Important: Application is hereby made for a permit to: When filling out forms on the E] Construct a new on-site sewage disposal system* computer,use epair or replace an existing on-site sewage disposal system* VRepair only the tab key or replace an existing system component—What? to move your cursor-do not use the return A. Facility Informatio key. Address or Lot# Q -,A ellwx'Q,"A� City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump ErGravity(choose one) ***If pump stem, attach copy of electrical permit to application*** ➢ Vj Conventional System (pipe and stone system) Y ❑ 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 d)eMake? What is theModeh 2. Owner Information _, Aq r"/1 lzl c I U t�- Namey I � Ad jess(if .ffer nt from a ove) �" ) �, l . City/Town State, , ,� ,� , �, 1 Email address Telephone Number° 3. Installer Information 6w�. y," 44 er /( Name _ Name of Compan r Address a0, City/Town State Zip Code 4 111;KeL K Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Comp y Address City/Town Slate Zip Code -4 ry D Telephone Number(Best#to Reach) P Application for Disposal System Construction Permit-Page 1 of 2 HEAL i Application for Septic Disposal System Construction Permit — TOWN OF ToDA .5 DATE NORTH ANDOVER MA 01845 $250.00—Full Repair $125.00 -Component l PAGE 20F2 t A. Facility Information continued.... 5. Type of Buildin Residential 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 Andover. I understand that until a final Certificate of Compliance has been issued by this Boar of Health;the ijstalled system is not approved. Name Date licati n Approv d By((Bid of He Ith Representative) Date Application Disapproved for the following reasons: For Office Use Only: Z Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump S sy tem? If so,Attach copy of Electrical Pei7nit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approvalletter, all paperwork received? 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 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: ('\ddress of septic sy"t_evyl) For plans by __ Relative to the application of (111stailer's nA�-) And dated �tjgrmfl(bite) Dated I oday's date) With revisions dated (Last 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 ptior 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 compan3�. 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,des, etc. As-built of verbal OK (or e-mail to: I'mialffide 4.)tCq)tow11t)f"11ort iandover.cotn) from the engineer must be—IT11- . -Ot()�-' o f"=1 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 homeowner, general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: ('Foday's Date) &,Z�k, � - !k ..z 11-21 V V 771171ne —Print) \13 (Name—Signed)