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Home My WebLink About1055 SALEM (formerly 1053) PERMIT ® ylmci.e�ri . Commonwealth of Massachusetts Map-Block-Lot 104.D0069 ----- ---------------- BOARD OF HEALTH Permit No North Andover BHP-2014-0495 P.I. FEE F.I. DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Robert K._Daigle,_Jr------------------------------------------------------------------------------- to(Construct)an Individual Sewage Disposal System. at No 1053 SALEM STREET as shown on the application for Disposal Works Construction Permit No. BHP-2014-049 Dated April 04,_2014 ---------------- -------------- -------------------------------- Issued On:Apr-04-2014 BOARD OF HEALTH - ------------------ ------------ ----------------------------------------------- Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALTH 1o4.D0069 -- -- ---- Permit No North Andover BHP-2013-1020 FEE $250.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Robert_K._Daigle, Jr. to(Construct)an Individual Sewage Disposal System. at No 1053 SALEM STREET --------------------------------------------- ----- as shown on the application for Disposal Works Construction Permit No. BHP-2013-102 Dated November 13 2013 Issued On:Nov-13-2013 ------------------------------------ BOARD OF HEALTH 4 " Construction Permit — TOWN TODAY'S DATE s& ANDOVER .A. 01845 � 250.00—Full Repair TH $125.00-Component Important: A licatio ,is here farms on the b made fora permit to: When filling out , Construct a new on-site sewage disposal system* 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.y the return A. Facility Information QAddress or Lot# is d '�V — - �ndn City/Town 2.-*TYPE OF,SEPTID SYSTEM*: tG:,i r"i t��l�t'40i�i (M41)OVER ❑ Pump ® Gravit Y (choose one) ** ,e 1 ***If pump system, attach copy of electrical p ermit to a pp lication* i �, tnd;t��E rw ti�At S wlt°� ❑ 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-Sox Present) S.A.S. 2. Owner Information Name Ad ress f dill rent from above) ' City/Town State Zip Code - - - Telephone Numbyr 3. Installer Information Nam �e Name ofC of,ompany Address City/Town State Zi C e . Telephone Number(Cell Phone#if possible please) 4. Designer Information Name --�I-� ^s, _ �fir"N e�J"�.��A e✓U^44"a,„� n:� rrl1.�:t YN d� Name of Company 6: Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 -? pplication for Sepfic, i L tee 0 M 6 n ructi n Permit — TOWN TODAY'S DATE a � ORTH V 8 $ 250.00-Full Repair $125.00 -Component PAGE 2 OF 2 A. Facility Information continued.... 5. 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 Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Health. Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use only: 1. Fee Attached? Yes—Z No 2. Pfo'ect li�lanaoer Obligation Form Attached? Yes. No 1 b �' 3. Pump System? If so,Attach copy ofElectrical Perms Yes No 4. Foundation As-Built?(new construction ronly): No (Fame scale as appfoved plan) 5: Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 i i • BOARD OF HEALTH 1600 Osgood Street, Suite 2035 North Andover, MA 01845 978-688-9540 APPLICATION FOR ABANDONMENT OF SUBSURFACE DISPOSAL SYSTEM (SEPTIC S)STEM) Pursuant to Section 310 CMR 15.354 Of the State Environmental Cade, Title V Name Phone 4 Address Contractor hired for work: Name ," . �. Phone c ) Address Date for scheduled abandonmentro The septic system at the above address has been abandoned according to 'T'itle V specifications. &bt V+ ta4l' Signature of Contract Method of septic tank abandonment(check one). O removal O sandfill (crush O other Name of Offal Hauler This form must be returned to the North Andover.Board of'Health. PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH REPRESENTATIVES ONLY Tn g A ent cti e p g Date ,s° }} SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: \aadless of seln6c sysrcl n) For plans by (r ,, Relative to (Ibzs€o�ac� s�n,aavnc:) ( And dated )3 ta With revisions dated ate ; a c Dated � Alla (["'sn pevc s;Cdcho ) 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 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, 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 n 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 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—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: lic°;alt:'lh l 7t.c� t:�ws°�«f�thortlh�t�dw,,encra�t;�,) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection tune. 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 Chart 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 my 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 plans No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. �p f Undersigned Licensed Septic Installer �' � (`I oday's 1)�atc.) ! �' A/ (1 at'lle .. Sig nckc.