HomeMy WebLinkAboutApplication - 296 RALEIGH TAVERN LANE 12/12/2014 TOWN OF NORTH ANDOVER
Office of'(., MM(C NI'I'YY' I')E �[,1.,,OIIMIi,P 'i' AN11 SEAVICES
HEALTH DEPARTMEN'T"
16011 QSCOOD STREET'; MJITIi", 2035
NORTI N Nt;D(M�I , MAYSAC`[ff_SI N"..S 01845 �
97 ,689.9540- Phone
Susan V.Sawyer,REIIS/11S 978.688.8476 FAX
"u bfic Health Director f;-iSIAH hearlffid (X11;kany!1Qfh,aathfyndove arar��
;WI GySf"V_f tcawvp grl�tf Y&fly ara<� rovc a ,_c�t
SEPTIC PLAN SUBMITTAL, FORM
Date of Submission:
Site Location: ""'°'m
Engineer:
New Plans? Yes m $225/Plan Check# l �r (includes 1" submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes No U 5 2015
Local Upgrade Form Included? " Yes No l, '
Fax#. C
Telephone % as
E-mail: r, 11 d�°
Homeowner
Name: [2A is 4' i °
OFFICE USE ONLY
When the sub sion is complete (including check):
I� Date stamp plans and letter
Complete and attach Receipt
1.2 Copy File;Forward to Consultant
1� -Enter on Log Sheet and Database
Co
2
w C:
o'
=
4
0 c � � > o o c c2.
ol -o 0 Cl) o � N
zt CL =r M a of 3 =- � °a Z ®.
N > @ @ u�i G) rn Q @ ° 3
j (D a @ rn ® Uj (D N m O ID
(a
U) (D (D o� 0 c
= 4�
@, C O O (@D (CD K
Q z N co
(D z cr rs .c
a) o o � b �. @ 0 ®. N
a s o CL N
0u ai a) (u m ® Cr �-
o (n CL a" _j _ ®.
C 0 c cti
Cn ❑ N
m = U) (@n u@i KD CO)
(n
n m Ui
= 1 (D
o �
o ❑ ❑ ❑ El
ro O O O O '(s
(D
-n
0
s (d C a ? o t@A '- (D
(!)
O
❑ @ - O El
0 10 p _< =1 w o n Co
9;<x
N (D
L7 N A
G @
tn� z @
O J g (D
Q
3 al c
® w m a m _o '- N
O rr
m _< � a. o
(6 ❑ t@n u@i car 0 � �
m m ED
(D m m
4 O
v
co
o ❑ ❑ 0"l
3 z z =
i °� o a - c
co
u�
0
m
w `
-n
0
C7 o
a
p
p Cj I® v
o
c 0
ro =3 0
ro
U7
.r a :3 a
CO 70
_°— (D a 0 g (0)ZI El `2 m
° -G m z CD
c N
❑ a ru p
M
a
9 �y�
N
❑ r � o�, � tD
m
i7 Q o `D L2
m 5 v 9 o ill
(((
o co to
C N
} CD CD
o
cn
o Cy CT
C/) (D Cf) N fd/>
Q c ..
tD
a s CZ EP
' ❑ �• b
N
cn
_ ro
ro fD
-n
o '0
cA o
N
c to m (b
m � 0
CO L
g Cb
m (D
`n v � CL
U)ro �
® m `
0 c d
N
07
cx
ro c°> z ro rn �D ill
ry x o ro %
a 3:
00 0
ro
ur
O
p
cu
o, a
'I'1
2
C " mm
!n
CL
0 >
CL
!r D
� o C/A �
Cr
° o
(D( D ° cD
a
o z A)
N eD
O a
a a �.
z 0 w
" to
3
" a c Cr
—.
CD —. M
Q- (D
a a
x° to
t ' ° o�
® ym N
V"
Q "U c
y
co
T t 2.
O V"
V!—I
U)
o
U)
a m a
K M
in 0 ® a
C
� �
� �
(n pQ mM
m
o �
O CO)
c/> y a CO)
m c °• U
U)
� ' ro
ca 0
m� o
® 9w (1)
® (®.
U)
N 0
m
co
m 0
w =r
a
OD
a t
X ` /
0
=
b
C31 R W tV 7� ®ago o o
a �
(n 0) G) o 0 ®t
: O 0
_ a 0 � :3 g z m cD m 0
CD (D m
o -, a v
a ro m
V7 (D= v � .-
:3 r — 0 �1
sa m' cr
-! G O �� (0)
N Fl d C.
� ro
9' 0
c7 (D m N
m ='
O
❑ m r 0
CL fi 0 cp
a C7 Q a 7b o a)
SD a
o' � _' -'e
o to (C) GL
ro r :3
N� `� 4
U7 (D CD (� °�
c 0 c = N
w
v
ro vy m �✓ m o
(° n�
3 (: s �
3 @ (D
m
0 0 ❑ a
1 ® O (�
0 0� 0:
�_ 4
(n c ro
m C = (�
(D
ro
(D o (D w a
ro 3 vi > m
U) ro ro
0 ga �, 0
N a m v°
0 (D 1,
(p ❑
nQi w (D
a n z m rn ID
O (1)- ((D,
00 0
ur aS
0
o'
0
a
0 4
{ Q. V 0
o o
CO)
4t P° ro (1)
rn a)
m °. m
to 4 W o o Cb ='
a 4
CA M tp• -h
0 q'
lr i z - vi
cC { 1 C o CO)
`°_o CD cr
-+ 0- . (D
o U)
o 0 0 U)
m 0
.,-n
ro
� � M
41 I f = uroi
CO
p r.
8
a I
o
C/) I
cn
,®
C3 m
K
D 0 4�
°a° C
co M
I N go
_
U
m
ca
ro
o �+
v �0
m
CD
cn ro
a �
00
C/)
0
o'
-n
0
0
o tJ LU 1>
® Q ❑ ❑ ❑
-0 x o
f I sum 0 CD� G7 C7 (D ® a 0
to -f cn °TM =r :3 = c C®
z 3 s =' a
Q ° obi (1) (D U) g
v of m o -6 (D
N �+ KD �
CL CD a _ a 0. -" a
❑ -' a O
c �e x. 3 w !�
3 3
o _ to !D a to a. N
tin O (a � � CD UC �
=W E a
vii fD G7 N a cr
;2 in (n c M (D fD
C1
a
J 0 (D 0 j(D
OL O
a =r �
fl? > X a
c (D c�n ro 0
CD N
"a � o a
CD m
cr
CL
N o
c
<
CL (D
c c
o X' rn
3 u° EvY 5 > 5' D S�>
=r
r
o
CO
® � c `p
N
a
N
CL
o a x
m
o ( m U)'
O o c m
in c rn -3'W S' cu 5' co 5'W co 0
rn a ro =r ::r =r =r
Cl) (1) co N
(Q �
P 4
V) �" p
En =r t%i
m CD CD CL
� a
cD
o
m i
o'
0
a 0 0 a o Z Z -I V1 0) Q (D 0
m (?D m a
m °' ny0
". 6) O
0
O
o n a = �' _ o -ti tD
(D 0 CL -(D c 1 c
i
o m ° p CD
(D N O ,�` c
n
o (D cr =r
C7r r � � paj (D CO)
co Z': 0 ((D
-iZ3 (D 0 B) (D
O Cr v �7 (D
O � (D
a3 (n � aR (0)o � U)
-13 ran = Q =T
a `�
O Cr w 3 O
3 v) c C (D m
c (a � a
or
N 3 =r Cf <
O < =�.
-h
O. -- (D
-n a ()
0 a O ® v � a' a a ou _ °
(D
i ° - 0) m
c r
CO 0 =ra
OD
LT 0 c
A o x a (D CL
(D 0
CL
O
O a CD CO
CD
a
O C = a.
a
x
m rn a- ((DD Ln
®- °- °
m (D ° o
a o MaO
0 (D � (Da
o� C x n
(D D
ni o (a' (n
a n a
v O (D
0
o a 3
Commonwealth lth of Massachusetts
- City/Town of
p
Percolation Tt
Form 1
USA,
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but
the information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
Important: It Information
When filling out °
forms on the
computer, use ------.____-� +_ H e Q „b
-------------------------------
only the tab key Owner Name
to move your
cursor-do not -- --" ---- ''� --
use the return Street Address c Lot#
key. k10—------- P - - — - �—
City/Town State Zip Code
VArib _. °°
Contact Person(if different from Owner) c% a ephone Number
B. Test exults
--------------------- -------- --
Date Time Date Time
Observation Hole# ----------- - -
Depth of Perc +® - - — -------------------- --
Start Pre-Soak I I ----------------
End Pre-Soak - l l !V --------------- ----------
Time at 12" 1 1 1.p
Time at 9" 1 V.
Time at 6" 2-
Time (9"-6") - i�t✓— !t --»------------------ ------------
Rate (Min./Inch) -- ------------
Test Passed: 19--l" Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
-11- V,1 r '� ----
Test Performed By:
-------- --------------------
Witnessed By:
Comments:
t5form12.doc•06/03 Perc Test•Page 1 of 1