HomeMy WebLinkAboutHealth Permit # 12/7/2015 Commonwealth of Massachusetts Map-Block-Lot
10630127
BOARD OF HEALTH
Permit No
North Andover BHP-2015-0918
FEE
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Rates-an
to(Repair)an Individual Sewage Disposal System.
at No 182 OLYMPIC LANE
as shown on the application for Disposal Works Construction Permit No. BHP-2015-091 d December 07,2015
Pp p
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Issued On:Dec-07-2015 BOARD O„F HEALTH
Y{, Application for Septic Disposal Sy tem
TODAY'S DATE
n tru do Permit- TOWN OF
$250A0"—Full Repair
NORTH $ MA 01845 $1125.00-Component
Important: Application is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal system*
forms the
computer,use ❑Repair or replace an existing.on-site sewage disposal'system*
y . epair or replace an existing system component—What.
only the tab key 7
to move your
cursor-do not
use the return A. Facility Information
key. / • _. I� �i -
Address or Lot# -
bir
Cityfrown 13
2:*TYPE OF SEPTIC SYSTEM :
➢ ❑ Pump cavity(choose one) F
If pump system,attach copy of electrical permit to application"`* a��� wi"i"i E 1�r �'��i°>i��Ia� V 61°
conventional System (pipe and stone system)
➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
❑Pressure Distribution S.A.S.(No D-Box)
➢ ❑Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES=(no further info.needed)
NO®(installer must specify brand of filter before DWC issuance)
What is the Make? Whatrs theMMM
2. Owner Information jtl
?Name
Address(if different from above)
9 r"
Cityrrown State Zip Code
Telephone Number
3. Installer Information
Name Name of Compan
Address
Cityfrown 6 State µ Zip Code
® t
Telephone Number(Cell Phone#if possible please)
4. Designer nformwation
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
dRTh
A I cafilor ..far S.e tic Disposal V$tem
I. •.� *Constructibn -Permit ' .
�TO N. -OF To®ars DATE
•�cwu +
• 1 A 0104 $.250.00 Full Repair
-T CHUs B , $125.00 Component
PAGE 2 OF 2
A. F_aCility°Information continued....
5. Type'of Building: EKeioildentlal 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 pro vislons 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 unt.11 a Certificate of Compllahce has
been Issued by this Board of Health.
Date
Ilca n Appro'I B $oard p
P f Health Re resentative •
me D2te
Application Dlsapprove ,for the following reasons:'
For Office Use Only:
1 Fee Attached?: Yes No
2,• ProjectAfanager OhYgatron Form Attached? Yes No '
31: ,M=? -1fS0j Attach coAlr ofElectrlcalPermrt';,; 'es No
4. Fiur*dadorr As Bu&?(hew construction-ronly), I'es No®
(Same scale as approved plan)
S. F1oorPlans?(hew construction'only): No
Applfcatf®n'or-plspp5al u�`ysterh%06n6trUd1ch permit:Rage 2 Of 2
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