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Commonwealth of Massachusetts — Map-Block-Lot
BOARD OF HEALTH 106.AO006
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Permit No
P.I.
North Andover BHP-2015-0342
F.I. FEE
t
$250.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
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to(Construct)an Individual Sewage Disposal System.
at No 64 FOREST STREET
as shown on the application for Disposal Works Construction Permit No BHP-2015 034
Dated ( August_--,2015
Issued On:Aug-12-2015
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— _- ----- ---------_-__-- _ BOARD OF HEALTH
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Commonwealth --- --
monwealth of Massachusetts
Map-Block-Lot
BOARD OF HEALTH 106.A0006
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North Andover
TIFICATE OF MPLIANCE
THIS IS TO CERTIFY,That t ual Sewage Disposal System (Construct)
by _ Todd Bateson
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-Installer- ------------------
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at No 64 FOREST STREET
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as been installed in accorde ith the provisions of TITLE 5 of the State Environm t 1 Code as described in the
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application for Dispoigal"Works Construction Permit No. BHP-2-015-034--
Dated August_12. 20__1.5__
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Printed On:Aug-12-2015
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BOARD OF HEALTH
, -
�, �s Application for Septic Disposal System /. -
TODA'Y'S DATE
Construction Permit — TOWN OF
NORTH ANDOVER, 01845 �$125.00-Com onent
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 epair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
key. ' �� /;D 6"`z ;`17
VQ Address or Lot#
K
Cityffown E
2.-*TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump ❑Gravity(choose one)
***If pump system, attach copy of electrical permit to application*"
➢ ❑C nventional System (pipe and stone system)
Vnri'ltrator or Siodiffuser(Gravel-Less)(Attach a copy of your certii thi`5� e�of system_)
➢ ❑ Pressure Distribution S.A.S.(No D-Box)
A ❑Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes `emu 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)
Wbatis the Make? What is theMode=fx
2. Owner Information /
Name
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
Name Name of Company
" D0N r_NTEnPn1SE S,INC.
Address ANDOVER,ivy 01810
Cityrrown State Zip Code
Telephone Number(Cell Phone#if possible please)
a. Designer Information
Name Name of Company
Address
City/Town State Zip Code
t / S >
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
1
Applipati'on.for Septic Djspogal System
A Construotionl 'Per" ' it °' TOW W. 'OF ToDAY'S DATE
ORTH ANDOVER, MA. 01845 $.250.00-Full Repair
ggCHUS $125.00.-Component
PAGE 2OF2
A. Faciiity.information continued....
5. Type*of Building: esidential Dwelling or❑Commercial
B. Agreement
The underslgned 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 Issue - y this Board of Health.
Name Date
Application Approved By: (Board of Health Representative)
Name Date
Application Dlsapproved.for the following reasons:
For O i'ce Use Only:
1 Fee Attached? Yes No
2.- PtojectMatiaget Bhlrgadon Form Attached? Yeo No
31: Pum LSJ=W? Ifso)Attach co,py ofElectrical Pernrit`:. 'cs� ' Nb
4. FoundatlbnAs Burlt:?(hew construction-ronly), Yeses No
(Same scale as apptoyedplaa)
S. FlootPlans?(new construction only).
No
Appl6 ldn'lor•plsposai 4sterii,:06nstruct1on Perm ft:Page 2 Of 2
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(alai r am a AM dated
Dated 1! ur a
o t Wftit revWotas dated
(Last revised date)
I understand the fol!owing obligations far momgemcat of this Prajcce
i.
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item duft•ahill.bq,applkable.
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