HomeMy WebLinkAboutApplication - 146 DEER MEADOW ROAD 2/4/2015 T (W N01011 ANDOVER
Office ice of(,'tIMNIL�IISIT ° D :VEL1IP ! E T , C' 1 SE'RY1 .'ES
1600 0SC.001:) STREET; StrlT E 2035
],��ORTH DtWi':ER, 1"1'ti SSMAIUSE C TS W 845
979A8 9540 P6aawrne
Su sin V.Sawyer,REIIS/1 S 9"8M8. 8 6— FAX
Public Heafth Director E-MAIL: h aaa�.dwa�c�c(IadFr�c&wvc.i-_ccasp
WE-B`i,ri w�,a¢.CI vvw mt-a��ru c>6-rl aetl<Ia-tc9ca a e.
SEPTIC PLAN SUBMITTAL FORM
Date of Submission:
Site Location: 14&
p
Engineer:
New Plans? Yes $225/Plan Check# (includes I" submission and one re-
review only),,,,,
R
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes No
H,,,
Local Upgrade Form Included? Yes No
Telephone#:(70) .47 Fax#Cj? 49 �
E-mail: ,: Yt 6 e V� k
Homeowner
Name:
OFFICE USE ONLY
When the submi ion is complete (including check):
Date stamp plans and letter
Complete and attach Receipt
( Copy File; Forward to Consultant
�' I /Enter on Log Sheet and Database
G! ,off
o'
aw rA 0 1 1
a
03 0
.
a
c°� _ � 'rl m C o 'f7 C7 (n p
ro ? 0 � (D fD p
m A CD m � 3
:3 (D 0) O (0 = m' p 0.
(D
ur — —
d1 !y In �.
[ C 4 0 (mD El((D ffi � O
n z 6 Q 0 < z
4 ((DD w C G a1.
cr 0
N
O GL a� 42
IT J
(n 0 fU
CL
w ❑ ❑ c
� ((D m (D (D
(3 = vy ur M (n U
0 CD
-p o W
o @ ❑ El El 3
m o 0 0 0 rF
Cl
CD 0
O CC
3 =e+ (A
O �
(C] C C �3 a ((DD r N B
a _ _ < (ro 3
(D 'a El m
(/) p m N {
C A O (D (D
m m
O N T
K (D =
to z J rn S
(D O O CL
En 3 CL
3 N
cr
0 *d
o Q
U.
(/� O z z J O Q ., N
"+ \ O
CL
w (D (D
(p N
p (D co
(D
V)
o ❑ ❑ a
2.
z z a
y — ° ° _ C
0 =_.
co
c�
a
-n
a
-n o o
C L 0 rr
m G)a
-b ® ►
-� u� _ o tD
3 c: �mi{ = i cz c
o D p�j U) (D IT1 m
C!
9 (D (D -h M
o 0 to 3 0) Z ;
O
d cD a oil rn m
c �• ®h
°' ma (� o' °a c O
(D a
_0 (D =3 a n B N
CL� l< o '
°1 DO A r-
n `° cr
rl F3,
(�D U) d m
-� < m
a O U)
(D
(A
w
F-1 a 0
ro O E _
a
° m (d m 8® ro
C
G
m (n
N ( < "O
`M ¢. 0 4
(D
(n _ m i
i
v
c (D
o v 0-
N (/1
CD
m3 co ( =• ((nn
o m (D
3 3 ro :3
o _T
® o
cD
in c �' rn
CL ro m
c°> ry t
U m
o + o
I 0
(a "-
(D
m m a ro
N �• O O m (D .«
CD n
00 N
r
�, rw
0
`n
4
0 0 0
C 7y e ®
n `� 3
s m
-a ' o
o O
:3 cr
0) `D' ®' U) (D ® tD
rn ®
cn 0 CD
2 :3 0
CO) -�L CD� °%
3o 0 ic
O ° m m
0) z j . (1)3
y �
c) =`
Q v a ��°
CL
V
V
CL
x N
O �
�-
c
a M y rt
U
o
a�
be e
cn
i
0
G) 0
c
V� < ;0)@ N
K ,g`,n
vx' 0 °—�
n ®s mm
I �n N
o U)
O Cl)
U
U) c Cl)
m °' U)
U ro
0
CD 0
® 0 )Q-�• o
0 �9
ED m
v
`° q
w :7
0
00
= r
m
� �l
c
411
O
_
'n
O
Y, _
C
" (m v 0 ro o
ro
Q rr 0 u, 0 0 ca
C. (D ro ro m
v Cd p
0 CD cv a < o
w Q O '
u < m ® 0 0
a ro C a 63 v �.
G) CD U ^ v
d = a C ea O O 3 L (D _ to
❑ w a =3
=' Cr =•
(D 0 o %, c N
v rn W (v (D ¢p
TI L
0 �_ n
=r @
® (D
❑ r ® tD
= O p) a�
(D ® p o @
@ o' J1
;2 �' nr• 3
g' 1• °1
-n caa
O @ -„ r C ro ro
{ =3
@ (n
a v (D a
CA
o
U) N CA
c 0 s c :3 m CA
3 El @_
o� �,
N N In N @~' O ,
N KO = ro
m
_. 3 @
CL
T O a
O to ® a
4.
3 .n-+ (D (p = 3
(/7 7 O @ �p
@ = 19I
�p Q El (p r4,,,
rn 0 ( C
co @ 0 o (D
3 w�
@ h
N Q gI s,
0
(L}7
Q ❑
@ (@D
m 0 Z rn m
c N ..
w
2.
a'
O py
$ v
CL
{ =* v ro 1 0
O 0
to a
C) ®' m eD
0 "� � 2
N o
a =3 < ®.
Ea a
o - m w
_ to
c 0 t�
r A !31
= �
@ 4 ( ::r
o (D N
a � �
a
@
n � �
a C' CA
rt m
y
w
CO
TI O
@
I
(D
Cl)
e @
v�r p
N I � 3 g
3 l ~ @ @ O
@ m 90
@
O
Cn 0
fD C O V
�p
i
w 0
CD
tC! �
Q N co)
O
N t9
(d
M @
O
-n
00
0
m
w
a
-' N -�
�' ° ■ ❑ ❑ ❑ ■
fD =. ro ca
m
G) a a 0
(p to (p a tp O -a -a -a a
cr to pl z = 3 =r En 3
a- CL ■
v N
w to (ca a
(D c c`� a -~
n a -� (n
s � m 4■ 3 3
o c° a m( a
" "a=7 ((n C: y, ° =r obi to
® ■ 3 ro o
CL
n S �p tot
.y n _ a (n
a =
CL
CL
a a =r
(C� D 717 C1 a
'0 a CD p
(D c L7 Q (D
U) ° m m
cr
CL
m
< O
o x. (n
� D J e > >
s s 9 =
0 vfi U uSDi w
c �
m c- (D
ro
C.
CD 0 O X
O O c m
U� c m W s' W W W
ro tll vroi v@i vi
cc fU
cn
a
o 0 a
(o
CD �*
w e�
ID
W o.
C/)
2.
m
0
:3
-n
0
-n -n 0 0
0 0
- 0 m
=r es� (D (1) a) (D
cD (D 0
a 0) 0 E ;z 0
ca _ 0
00 j
(D -0*
CL =r 0
=3 0
(n U) M
TOA a) —
- W :3 a)
z m
OL C� cL 3 0
0 3 V-- - 0 0 0
CD m 0 0
=r 0 =3 -h
(D
'a 0 cp
=r 79 0 0 (D
=3�
U) m
CD CD aba
0
<
0 ZP 0 (D
(D
CD
C 0) (D
=r p_Z OL
W ch s 00 uy,<
pi C)
0 0 =r =r
0 g:
0 0 fn
cr
co
at -0
0
m 3
(Di 3 --a 3
C:) (D (D
=3
=r
0 CD 3
o
(D m
3 co CL
ry =r a" < -h
3 0 < =;-
#� 0 0
Q. (D
0'n 10 -
-,j U) 0 (D 0
0 0 03 0 0 0 0 =3
0 - =) -
=r U)
(D (D
CL 0
0 <
a) CD - cn
Ul) 3: 0 E 0
2. M - a)m 9
(D
< != a
0
U)
LT 0 9 V\ CD
(D
=r gym ('
0 - @
:3. a.0
cn
3
(D QL 0
EP C)
(D
0 (D
0 x
C/) =ra
(D CD CD m
CL
(a UJ
m m 2. Er
0
M a 0
:3 0
0 (D < :3
CL x(D a
(D (D
0 (-D* cn
CD o
:3-n
0 =3 0
(D
CL 3
Commonwealth lth ®f Massachusetts
City/Town Of
Percolation Tt
Form 12
V
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: ite Information
When filling out °
forms on the ( ,y
computer, use ---
only the tab key Owner Name
to move your
cursor-do not Street Address or Lot#
use the return �� I
key. -
City/Town State Zip Code
Contact Person(if different from Owner) Telephone Number
B. Test Results
j-
Date Time Date Time
Observation Hole# -- I — --
Depth of Perc - ------ --
Start Pre-Soak
End Pre-Soak -- -
Time at 12"
Time at 9"
Time at 6" — - -—
Time(9"-6")
Rate(Min./Inch) — - - -
Test Passed: Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Test Performed By:
Witnesse y:
Comments:
t5form12.doc°06103 Pere Test°Page 1 of 1