Application for Septic Disposal System Construction Permit – TOWN OF
NORTH ANDOVER, MA 01845 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key.
TODAY’S DATE
$350.00 - Full Repair $175.00 - Component
Application is hereby made for a permit to: Construct a new on-site sewage disposal system* Repair or replace an existing on-site sewage disposal system* Repair or replace an existing system component – What? ________________________
A. Facility Information Address or Lot #
City/Town
2.- *TYPE 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) 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? ____________________What is the Model? ___________________
2.
Owner Information Name Address (if different from above) e-mail address (optional)
3.
City/Town State
State
Email address
Telephone Number
Zip Code
Installer Information Name
Name of Company
Address City/Town State
State
Zip Code
Telephone Number (Cell Phone # if possible please)
4.
Designer Information Name
Name of Company
Address City/Town State
State
Zip Code
Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2
Application for Septic Disposal System Construction Permit – TOWN OF
NORTH ANDOVER, MA 01845
TODAY’S DATE
$350.00 - Full Repair $175.00 - 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. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. 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___
No___
2. Project Manager Obligation Form Attached?
Yes___
No___
3. Pump System? If so, Attach copy of Electrical Permit Applicant received copy of “Electrical Inspection Notes for Septic Systems” Handout?
Yes___
No___
Yes___
No___
4. Reviewed approval letter, all paperwork received?
Yes___
No___
Missing:_________________________________________________________________________ 5. Foundation As-Built? (new construction only): (Same scale as approved plan)
Yes___
No___
6. Floor Plans? (new construction only):
Yes___
No___
Application for Disposal System Construction Permit • Page 2 of 2
Application for Septic Disposal System Construction Permit .pdf ...
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