HomeMy WebLinkAboutHealth Permit # 1/15/2013 o� q* Application for Septic Disposal System /--/�-/� _
a TODAY'S DATE
Construction Permit-TOWN OF
�" ORTH ANDOVER,MA 01845 $250.00-Full Repair
$125.00-Component
Important. Application is hereby made for a permit to
Man filing out ❑Construct a new on-site sewage disposal system*
forms on the
wmpmer,use �j Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑Repair or replace an existing system component-What?
key -do not
meter°`" A.Facility Information
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2.-*TYPE OF SEPTIC SYSTEM*:
1p.❑Gravity(choose one)
mp system,attach copy of electrical permit to application***
❑Conventional System(pipe and stone system) aez
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)(Attach Draft Maintenance Agreement)
❑Pressure Dosed(D-Box Present)S.A.S.
2. Owner Information
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Name
Address(Iffd,nlf r
Chy-a wn State Zlp Code
Telephone Number
3. Installer Information
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Name Nam of Company
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Address n / - H
CIyIT wn State Zip Code
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Telephone Number(Cell Phone#ifpossible please)
a. Designer Information
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Name Name of Company
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Addr ss
City/TO— State Zip Code
Telephone Number(Beef#fo Reach)
Applloalion for Disposal System Construction Permit•Page 1 of2
�r o`Application for Septic Disposal System TODAY'S ATE/3
Construction Permit—TOWN OF
" ° NORTH ANDOVER,MA 01845 $250.00—Full Repair
$125.00-Component
PAGE 2 OF 2
A.Facility Information continued....
S. Type of Building:® esidential 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,""I/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'sued by this eoartl f Health.
y Date
Application Approved By:(Board of Health Representative)
Name 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. P=p Susiem?Ifso,Attach copy o£ElectricalPermit Yes No '..
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved pla)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2.f2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
Rax p6 ns by �c'K/tt�AG�c zH/MP2t�h.��ucrp
Relative to theapphrauonof Q,4 as 6S
Qns�.�llecs lame) And dated l{`"p"'�a-"
/3 �:�pna�a
Dared �
i With xevi—,,dated �Z
t (Ins.......d da,,)
I understand the following obligations for management of this project:
I. As the installer,I am obligated to obtain all permits and Board of Health approved plans prior 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,l 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 S50.00 fine being levied against me and/ox
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-Enguicer must first do their inspection for elevations,ties,em.
As built of verbal OK(ox -mail kc t.althd< t )t ofn it t id,,cxytmin)from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time.Installer must
be present fox 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 ou-site.
4. As the installer,I understand that only I may perform the work(o6bar lban tin plc axcavalion)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 s stems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of mylicense to operate in the'I'own 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,piper,stone,vent,pump ebamber,retaining mall 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, any other persons shall absolve
e of this obliggfi,u.
Unddersi-g-n�ed Licensed Septic Installer: ("Today's Datc)
(N tit Ng )
North Andover Health Department
Community Development Division
December 18,2012
Elizabeth Andrukaitis
554 Foster Street
North Andover,MA 01845 '...
Re.Subsurface Sewage Disposal System Plan far 554 Faster Sheet Map 1048 Lot 5 -
Dear Mrs.Andrukaitis:
The proposed wastewater system design plan for the above site dated November 8,2012 and
received on November 19,2012 has been reviewed and the final revision dated December 8,
2012 has been approved for a 3 bedroom(maximum 7 room)home.This approval includes the
following as granted at the regularly scheduled Board of Health meeting on November 15,2012.
1) Local Upgrade for a Vertical offset from S.A.S.to Estimated water table from 5 feet to 4
feet
2) Local waiver from Distance from S.A.S.to wetland from 100 feet to 63 feet
3) Local waiver from Distance from a septic tank to a wetland from 75 feet to 52 feet
The design has been approved for use in the construction of areplacement onsite septic system.
This plan is generally good for 3-years from the date of approval however,as this is for a repair
system,this is reduced to 2-years.
During this time,a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer,designer and the Town of North
Andover.In the event an imminent health problem such as sewage backup into the dwelling is
occurring,the North Andover Board of Health may reduce the time period for which this plan is
valid.
This approval is also subject to the following conditions:
1. Please keep a copy of the form 9b for your records.
2. With the understanding that the granting of the reduction of the distance to the high
water table restricts future expansion of the buildings flow capacity beyond 330
Page 1 of 2 '..
North Andover Health Department,1600 Osgood Street,Building 20,Suite 2035,
North Andover.MA 01845 Phone:978.688.9540 Fax:978.688.8476
554 Fostes Street December 18,2012
gallons per day(3 bedroom,maximum 7 rooms),unless the system is upgraded to a '...
compliant distance of five feet to the water table.310 CMR 15.405(4)
3, If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation,the originally issued Disposal System Construction
Permit is void,installation shall stop,and the applicant shall reapply for a new
Disposal Systems Construction Permit(3 10 CMR 15.020(1)).
4. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and
municipal requirements are met. These may include review by the Conservation
Commission,Zoning Board,Planning Board,Building Inspector,Plumbing Inspector
and/or Electrical Inspector.The issuance of a Disposal System Construction Permit
shall not construe and/or imply compliance with any of the aforementioned
requirements.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Sincerely,
san-
san Ye4.wyr HS,PubHc H �
cc: Merrimack Engineering
File
Page 2 of 2
North Andover Health Department,1600 Osgood Sheet,Building 20,Suite 2-36,
North Andover,MA 01845 ]],one:978.688.9540 Fax:978.688.8476