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Home My WebLink AboutMiscellaneous - 230 GRAY STREET 1/6/2016 (2) TOWN OF NORTH ANDOVER T#j Office of COMMt)NITY DEVELOPMENT AND SERVICES HEALTH '. ENT 400 OSGOOD STREET NOR'IJ[ ANDOVER, MASSACfKJSE'1-FS 01845 SLIS',111 Y. Sawyer, R S/RS 978.688,9540—Phone; Public Health Nrector 978.688.8476—FAX SEPTIC SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: Lot 5 Gray Street MAP: LOT: INSTALLER: Charlie Todd DESIGNER: Joe Serwatka PLAN DATE: Last Revised 8/1/05, Received on 9/21/05 BOH APPROVAL DATE ON PLAN: 10/6/05 INSPECTIONS DATE OF BED BOTTOM INSPECTION: 11/4/05—Michele Grant DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE 1. GRAVITY DISTRIBUTION...❑ 2. PRESSURE DISTRIBUTION...❑ 3. PRESSURE DOSING...❑ 4. HOLDING TANK...❑ 5. ADVANCED TREATMENT...❑ 6. OTHER...El PUMP SYSTEM COMPONENT SUMMARY FROM PLAN 1. GALLON TANK = 2500 2. LOADING OF SEPTIC TANK-- 3. GALLON PUMP CHAMBER = 2550 4. LOADING OF PUMP CHAMBER 5. TYPE OF SAS = Infiltrator 6. DIMENSIONS AND DETAILS OF SAS: 47.5 x 43.5 Comments: There is a new benchmark. I marked it on the Plan. I asked the Installer to call the engineer regarding the new benchmark. Page 1 of 4 TOWN OFNORTH ANDOVER Office of COMMUNITY DEVELOPMENTAND SERVICE S14 1 .,A1,111 DEPARTMENT 400 OSGOOD STREET NOR111 ANDOVER, MASSAC14L)SETI-S 01845 CH Susai-i Y. Sawyer, REHS/RS 978,688.9540 Photie Public Health Dhvctor 978.688.8476- FAX SITE CONDITIONS 1. Existing septic tank properly abandoned...❑ 2. Internal plumbing all to one building sewer...❑ 3. Topography not appreciably altered...❑ SEPTIC TANK 1. Bottom of tank hole has 6" stone base... 2. Weep hole plugged...❑ 3. Tank has been installed (H-10 or H-20) Tank Size: 1,000; 1,500; Other Monolithic or 2 piece (circle)...❑ 4. Water tightness of tank has been achieved (Visual)...❑ 5. Inlet tee installed,under access port...❑ 6. Outlet tee (gas baffle or effluent filter) installed,under access port...❑ 7, Cover to within 6" of final grade installed over one access port,must be over outlet of tank if effluent filter is present- Inches of Tank...❑ 8. Hydraulic cement around inlet& outlet...❑ Comments: There are new benchmarks. I asked the installer to make sure he removes larger rock out of the bed bottom. PUMP CHAMBER 1. Bottom of tank hole has 6" stone base...❑ 2. Weep hole plugged...❑ 3. Pump Chamber Installed Gallons; (H-10 or H-20) (Monolithic or 2 piece) (circle) 4. Inlet tee installed,under access port...❑ 5. Pumps) installed on stable base...❑ 6. Alarm Float Working...❑ 7. Pump On/Off Float Working...❑ 8. Total # of Floats... 9. Drain hole in pressure line...❑ 10. Cover to within 6" of final grade installed over one access port...❑ 11. Water tightness of tank has been achieved—Visual or Vacuum Test or Water held for 24 hours (circle) 12. Hydraulic cement around inlet&outlet...❑ Comments: Page 2 of 4 TOWN OF NORTHANDOVER Office, of("OMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ol 400 OS GOOD s'rREET NOR11-1 ANDOVER, MASSA CH U SE-11"S 01845 C Stisan Y. Sawyei•, REHS/RS 978.688.9540-Phone PLiblic Health Dfi°ectoi- 978.688.8476 FAX D-BOX 1. Installed on stable stone base...❑ 2. Inlet tee (if pumped or >0.08'/foot)...❑ 3. Hydraulic cement around inlet&outlets...❑ 4. Observed even distribution...❑ 5. Speed levelers provided (not required)...❑ Comments SOIL ABSORPTION SYSTEM 1. Bottom of SAS excavated down to C Soil Layer, as provided on plan...IK 2. Size of SAS excavated as per plan...FX_I * 3. Tide 5 sand installed,if specified on plan...❑ 4. 3/4-1/2" double washed stone installed...Ll 5. 1/8- /2" (pea stone) double washed stone installed...L1 6. Laterals installed and ends connected to header (and vented if impervious material above) ...❑ 7. Orifices @ 5 & 7 o'clock positions...❑ S. Gravel-less disposal systems: type, number and location as per plan...❑ 9. Elevations of laterals installed as on approved plan...❑ 10. 40 MR HDPE barriers installed...❑ 11. Retaining wall (boulder / concrete / timber / block) ❑ 12. Final cover as per plan ...❑ Comments: *Trenches shifted a couple of feet on North side due to mistake on tree location. PRESSURE DISTRIBUTION 1. # of Inches in Manifold 2. Laterals installed with end sweeps; Size: Material: 3. Squirt Test: Feet in height 4. Equal distribution to all laterals 5. Orifice size inch as per plan Comments: CONTROL PANEL 1. Alarm&Pump are on separate circuits...❑ 2. Alarm sounds when float is tripped...❑ 3. Location of control panel: 4. Rated for exterior if placed outside...❑ Comments: Page 3 of 4 TOWN OF NOR'"f'H ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICIES HEALTH DEPARTMENT 400 OSGOOD SI'REET NORI'll ANDOVER, MASSACTI[JSEI-TS 01845 s SLtsaii Y. Sawyer-, REHS/RS 978.688.9540 Phone PLiblic I lealth Ditvctoi• 978.688.8476 FAX SYSTEM ELEVATIONS 1. Benchmark: 2. Rod at Benchmark: 3. Height of Instrument: INVERT ON DESIGN INVERT PLAN ELEVATION Building Sewer OUT Septic Tank IN Septic Tank OUT Distribution Box IN D-Box OUT Manifold Lateral 1 HIGH Lateral I Inv Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Page 4 of 4 TOWN OF NORTH ANDOVER %AORTH Office of CONINIUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 8 CH 978.688.9540—Phone Public Health Director 978.688.9542—FAX SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS: MAP: LOT: S:/' , , ( INSTALLER: Z.- DESIGNE R: PLAN DATE: -4� V BOH APPROVAL ATE ON PLAN: DATE OF BED BOTTOM INSPECT DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION' SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION PRESSURE DOSING HOLDING TANK ADVANCED TREATMENT OTHER COMPONENT SU MARY FROM PLAN .�GALLON TANK =' LOADING OF SEPTIC TANK GALLON PUMP CHAMBER f i LOADING OF PUMP MB�c:R TYPE OF SAS TAILS DIMENSIONS AN D TAILS OF SAS: SITE CONDITIONS Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: Page I of 4 TOWN OF NORTH H ANDOVER rh Office of COMMUNITY DEVELOPMENT AND SERVICES ,r� �``` � °"00 HEALTH DEPARTMENT m goo OscooD STREET NORTH ANDOVER, MASSACHUSETTS 01845 X13 ppro nrPR�g s 1emu Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542--FAX SEPTIC TANK Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, under access port ❑ Outlet tee (gas baffle or effluent filter) installed, under access port ❑ inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet AWµmM c " Comments: / t�� °., � � � w~z� ,.,�. .� PUMP CHAMBE ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed (H-10 or H-20) (monolithic or 2 piece) ❑ Inlet tee installed, under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off float working ❑ Drain hole in pressure line ❑ inch cover to within 6" of final grade installed over one access port ❑ Water tightness of tank has been achieved Visual or Vacuum Test or Water held for 24 hrs ❑ Hydraulic cement around inlet & outlet Comments: Page 2 of 4 TOWN OF NORTH ANDOVER of ND RTh q Office of COMMUNITY DEVELOPMENT AND SERVICES a2 b�'" °"�0 HEALTH DEPARTMENT 400 OSGOOD STREET ^, NORTH ANDOVER, MASSACHUSETTS 01845 �,SS ° S try ACHUSE Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.6889542—FAX D-BOX ❑ Installed on stable stone base ❑ Inlet tee (if pimped or >0.087foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution Comments: 1:1 Speed levelers provided (not required) SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 '/2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ laterals installed and ends connected to header (and vented if impervious material above) ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravelless disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: PRESSURE DISTRIBUTION ❑ inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals El size inch as per plan Comments: Page 3 of 4 TOWN OF NORTH ANDOVER f „ORTN Office of COMMUNITY DEVELOPMENT AND SERVICES 3?O`S1 ao e14L HEALTH DEPARTMENT � p 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 C.H t5 ,SS�cHUS USet Susan Y. Sawyer, REHS,RS 978.688,9540—Phone Public Health Director 978.688.9542—FAX CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel El for exterior if placed outside Comments: SYSTEM ELEVATIONS Benchmark: Rod at Benchmark: Height of Instrument: INVERT ON DESIGN PLAN ELEV 0)-TOP OF PIPE INVERT ELEVATION Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN D-Box OUT Manifold Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Page 4 of 4 "� � �m � �' R m ou m �i � � '�' Dm J � � w�u � �� ice^ �� .�, � �, � � � uv. � ou ��" ro 4�� m ��m �� 1 � � �t � i�� .... @�i IL.. � "', r , � wumw � J �� '�. ',tlil "".9.� .��:��qN" � �� ..- �.. ... s m" o � b wm ��, � �-� ��" � ��m � � ` < INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the pmpertyat relative tothe application _ �� of dated — for plans bv ' and doted 6C with revisions dated |understand the following obligations for management o[this project: |. As the installer uou obligated to obtain all permits and Board of Health approved plans prior to performing any work on u udo. l must have the approved p|uoo and the poruzk on site when any work io being done. 2. As the installer must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system ia not ready then item three shall beapplicable. 3. As the installer uourequired to have the necessary work completed prior to the upp|ioub)o inspections as indicated below. J understand that requesting an inspection, vvkbnud oonop|ndou of the items iu accordance with Tile 5 and the Board of Health Regulations may result ino$5O.O0 fine being levied against onycompany. a) 8oKono of Bed ' goumuUy first inspection unless there is u retaining vvuU which should be done first. Installer must request the inspection but does not have tohopresent. b) Final inopection — Boginoo/ muatDratdotboir lumpoobon for elevations, ties, cru. Ay'bn8bor verbal 0K from engineer must be submitted to Board of Health, after which installer ooDm for iuuDcodon time. Installer must be pn:ouot for this 600;ocdoo. With pump system all electrical | work must bc ready and able ro cause pump to work and alarm tnfunction. o) Final Grade—Installer must request inspection when all grading iacomplete. Does not have tohu � | on site. 4. As the installer I understand that only l may perform the work(other than mbopio cxuuvu1iou) / required to complete the installation of the system identified in the attached application for installation. l further uudmzduud that work by others unlicensed to hnduU aoytiu uyotm000 in Nndb Andover can constitute reasons for dcuiu] of the myutmou" 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 TuntuUer } understand that 1 must be on site during the performance of the following construction steps: u) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone toboused. o) Final inspection hy Board oC Health staff n/uouooltuu' d) Installation of tank, D'hox' pipes, a0ono' veut, pump obum6cz, retaining p/aK and other components. 6. As the installer I understand that I uoo solely ,uopoouib\c for the installation of the system as � � per the approved plans. No instructions by the homeowner, general contractor, or any other � persons shall absolve ouuof this obligation. | Undersi d Licensed Septic Installer / ` Date: �� wee 6182 1 'S Date... ............ ........ TOWN OF NORTH ANDOVER ; pORTH PERMIT FOR WIRING SSACMUSE� This certifies that ...........rte i C..l. .....j.' ..ji/?::'`.1..... .:. ar.: .../.. has permission to perform ...... ` -/. .. .... .... .;:.1. ..f... ...••....•..•. wiring in the building of.............. ..... ... .. .. ty . n at........4�.:�� :....� /..!�... .........i� .. . ,North Andover,Mass. Fee ....... .:...... Lic. ................!• . .... . ..... ..., .... .,}....... ELECTRICAL INSPECTOR J Check # 7 2a ' V TOWN 01" NORTH ANDOVER Office ofCOMMUNITY DEVELOPNIENTAND SERVICIES HEALT11 DEPARTMENT" 400 OSGOOD ST11'1J' N01�,A11 ANDOVER, MASSACJ IUS Errs 0 1845 Ell Susan Y. Sawyer 979,688,9540-Phoj.�e Publk-,,11calth[hrector 97(8,68&9542 -- FAX October 6,2005 Litchfield Company 126 Cambridge Street Burlington,MA 01803 RE: Subsurface Sewage Disposal System Plan for Lot 5 Gray Street,Map 107D,subdivision of Parcel 6,North Andover,Massachusetts Dear Property Owner, The North Andover Board of Health has completed the review of the septic system design plans,for the above referenced property.These plans,dated August 1,2005,have been approved for a five(5)bedroom,maximum 11- room home.Note that page 2 is showing new pump information and is dated September 17,2005. As stated in the previous approval,the design has been approved for use in the construction of a new onsite septic system. This approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work,and a Certificate of Compliance must be endorsed by the installer,designer and the Town of North Andover.Please note the condition#2 below. This approval is subject to the following conditions: 1, Title V regulation section 102C-requires 2 deep hole observation tests in the primary and secondary disposal areas.Lot 2 primary and secondary areas only have 2 deep hole tests. According to agreements between the BOH representative and the engineer,the onsite decision was made to reduce the required number of tests for each system.In this case,due to the lack of soil information on the south side of the system,this plan approval conditions that upon construction,if the BOH inspector finds that soil conditions vary within the boundary of the system,lie/she may require a confirming test hole prior to allowing the installer to move forward with the system construction. 2. The issuance of the disposal works construction permit is contingent upon the receipt of a foundation as-built of the dwelling.The as-built must be in a scale of I"=20'. 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. 5. This system is designed to pump to a distribution box.Please note that the electrical inspector regularly requires an external shut off within site of the pump.Please have the electrician contact the inspector for details on this issue. 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 6. As per the Engineering notes,before construction,the pump and electrical boa must be approved by the engineer. The health department is now withholding the installation permit until the electrical permit has been issued. Please provide proof upon application by the installer. The Health Department may be reached at 978-688-9540 with any questions you might have. Si e ly, San Y. Sawyer,REH S ` ublic Health Director cc: Joe Serwatka,P.E. TOWN N OF NORTH ANDOVER 0, Office of C ONOMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET ° BP °�hTCO PPR`I(y NORTH ANDOVER, MASSACHUSETTS 01845 ACHUS�c Susan Y. Sawyer 978.688.9540—Phone Public Health Director 978.6889542—FAX October 6,2005 Litchfield Company 126 Cambridge Street Burlington,MA 01803 RE: Subsurface Sewage Disposal System Plan for Lot 5 Gray Street,Map 107D,subdivision of Parcel 6,North Andover,Massachusetts Dear Property Owner, The North Andover Board of Health has completed the review of the septic system design plans,for the above referenced property.These plans,dated August 1,2005,have been approved for a five(5)bedroom,maximum 11- room home. Note that page 2 is showing new pump information and is dated September 17,2005. As stated in the previous approval,the design has been approved for use in the construction of a new onsite septic system. This approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work,and a Certificate of Compliance must be endorsed by the installer,designer and the Town of North Andover.Please note the condition#2 below. This approval is subject to the following conditions: 1. Title V regulation section 102C—requires 2 deep hole observation tests in the primary and secondary disposal areas.Lot 2 primary and secondary areas only have 2 deep hole tests.According to agreements between the BOH representative and the engineer,the onsite decision was made to reduce the required number of tests for each system. In this case,due to the lack of soil information on the south side of the system,this plan approval conditions that upon construction,if the BOH inspector finds that soil conditions vary within the boundary of the system,he/she may require a confirming test hole prior to allowing the installer to move forward with the system construction. 2. The issuance of the disposal works construction permit is contingent upon the receipt of a foundation as-built of the dwelling. The as-built must be in a scale of 1"=20`. 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. 5. This system is designed to pump to a distribution box.Please note that the electrical inspector regularly requires an external shut off within site of the pump.Please have the electrician contact the inspector for details on this issue. 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 6. As per the Engineering notes,before construction,the pump and e►'.vIrical box must be approved by the engineer. The health department is now withholding the installation permit until the electrical permit has been issued.Please provide proof upon application by the installer. The Health Department may be reached at 978-688-9540 with any questions you might have. Public y, . Sawyer,REH S ealth Director cc: Joe Sezwatka,P.G. l FORM U ® LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments�having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from Compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS TI � � a .. APPLICANT r PFI LOCATION: Assemes Map Number PARCEL 119 SUBOIVISIO LOT ( ) *"****OFFICIAL USE L E I TIC TOWN a / D NSERVATION ADMINISTRATOR AT APPROVED , m-- l ATE REJECTED ° COMMENTS t"tSiLi``ic-1�_ ' _ TD LALANNER� AT PRO AT R JECT D COMMENTS FOOD INSPECTOR-HEALTH ATE APPROVED ATE REJECTED_ . SEPTICNNSPECTOR-HEALTH DATE PRO DATE REJECTED COMMENTS PUBLIC WORKS v SEWERIWATER CONNECTIONS .. w , .. r . • w . ,e DRIVEWAY PERMIT ,� .,� <- FI E DEPATMENT1'fr RECEIVED BY BUILDING INSPECTOR AT Revl ?Im T 4,, Application r r Septic Disposal vat °rt- TODAY'S DATE F ; On tru tion Permit ® -._ `I` 014 250.00-Fun R� per.' __ sti�`y ' 125.00 -Component Important: ApplicatioD is hereby made fora permit to: When filling out Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your ❑ Repair or replace an existing system component cursor-do not use the return key. A. Facility Information �_6 reb Address or Lot# .✓U t-Ifld��r�� e� City/Town 2.-*uYPE OF SEPTIC SYSTEM*: Pump ❑ Gravity (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) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present) S.A.S. 2. Owner Information Name Address(if different from above) City/Tow State Zip Code Telephone Number 3. natal er Information aLlide-," Name.� _ Name of Company Address 1' ItOv,'GA car C City/Town Telephone Number(Cell P /I le please) 4. Designer Information Name Name of Company P-6 08y Jp)10 Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 A°RTy Application for tic Disposal Sys 6 `, ° TODAY'S DATE tem on tr ction Permit NORTH 014 $ 250.00-Full Repair ''wssq�ft{sk��y ANDOVER, $125.00 -Component PAGE 2 ®F2 A. Facility Information continued.... 5. Type of Buildina:`VResidential 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, and not to place the system in operation until a Certificate of Compliance has been issu d by this Board of He h. Name Date Applicat' n Approved B /(Board of Health Representative).r Date Application Application Disapproved for th 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 of Electrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes i/ No (Same scale as approved plan) S. Floor Plans?(new construction only): Yes t/� No Application for Disposal System Construction Permit-Page 2 of 2