HomeMy WebLinkAboutHealth Permit # 9/18/2007 Commonwealth of Massachusetts Map-Block-Lot
w 107.D-0049
Board of Health Permit No
�
, North Andover
BHP-2007-0267
t.
° P.I. FEE
Ss U,
F.I. $250.00
Disposal Works Construction Permit
it
Permission is hereby granted John_Soucy ____------_---_____
to(Repair)an Individual Sewage Disposal System.
at No 469 BOSTON STREET
a as shown on the application for Disposal Works Construction Permit No. BHP-2007-026 Dated September 18,2007
-- -
Issued On: Sep-18-2007 Board of Health
Caw
Map-Block-Lot
„ Commonwealth of Massachusetts
107.D-0049-
Board of Health
North Andover
� Certificate of Compliance
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair) 1
by John Soucy
--- ----
Installer
at No 469 BOSTON STREET
------ - - ------ - ---- - ------ ------ - ---
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-2007-026-_ Dated- September 18,2007
I
Printed On: Sep-18-2007 Board of Health
Ilc.pti for Septic Disl3osal System
� n�tru tl Permit TO Y'S DATE
ORI'H ANDOVER MA 0184 $ 250.00®Full Repair
$125.00 - Component
rAC��us�
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 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?
cursor-do not
key the return A. Facility Information lei
Y
rab Address or Lot#
City/T n
2. PE OF SEPTIC SYSTEM'":
`l Gravity (choose one)
** If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiff user(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/Town State Zip Code
Telephone Number
3. Installer Information
_ -aL c
Name / Name of Company
Address y
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Desiciner Information
C%. f ',L,Name &ame--1
of Company
Address w r
City/Town Ap State",,, Zip Code
_ 6&- -
Telephone Number(Pest#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
pplication for Segfic Disposal System 17
- Construction Permit — TO 'S DA
TOWN OF
$ 260.00-Full Repaie��/
NORTH ANDOVER, MA 01845
$125.00 -Component
'VACHUS
PAGE 2 OF 2
A. Facility Information continued....
s. Type of Building 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 An ver, and not place the system in operation until a Certificate of Compliance has
been i u d by this r of Health.
9/t
/ame Date
/Appli on Approved B oard of Health Representative)
t
e
Application IDIsapproved for'Uhle following reasons:
For Office Use Only:
L Fee Attached? Yes All No
2. Project Manager Obligation Form Attached? Yes No
3. Pump Svstem? If so,Attach copy of Electrical Permit Yes JAITO
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit-Page 2 of 2
SEPTI,',, SY'S'TEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
C"S 'A '34.
(,address of septic systern) For plans b,
Relative to the application of 0 t", e
(Install l
er.s I ante) And dated 67
'
(()Pial dafe)
Dated ate) With revisions dated '�44-
Past revised 14e)
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 Rdor 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 C0122vgDy
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, ties, etc.
As-built of verbal OK (or e-mail to: h_e,�ilthde-)t q)�towtic��fn(.)rth�aiido,�,�er.co�n-i) from the engineer-must
be submitted to the Board of Health, after which 'installer calls for an inspection dine. 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=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 12Tans. Na instructions by the homeowner, general contractor, or ny other sons shall absolve
I th r 12er all
me of this obligation.
Undersigned Licensed Septic Installer: l'oday's 1)ate)
C L4
7aii-It"- Print) N'acne ed)