HomeMy WebLinkAboutApplication - 64 STANTON WAY 1/28/2014 TOWN O I'NK01 T11 AT'd)OVEN,
Office ail`("tbi '1M1..iNITY [)EVEL0PM1?; T N1) SE1Mf:ES
HEALTH DEPARTMENT
1600 OSGOOD S'1'tWET; SLATE 2035 �
NORTH ✓ NL)OVFII� , v ASSsC' CtS1,. . S 01845
97K688,9540 Phone
Public Ifealth Director 1s S 11. 1 a�..M.t.1'ti<la frf(a�;t,�,owsaaal'i�pa�a�htr�cll,gy�cr a+_ra.l,k,
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SEPTIC PLAN SUBBITTAL FORM
Date of Submission:
Site Location:LOT 16-4 STANTON WAY
Engineer: CHRISTIANSN & SRGI, INC.
New Plans? YesX $225/Plan Check# 3,�, 31,5 (includes 1St submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes NoX
Local Upgrade Form Included? Yes NoX
Telephone#:978-373-0310 Fax #:978-372-3960
E-mail:phil@csi-engr.com
Homeowner
Name:
GREEN & COMPANY, 11 Lafayette Rd., No. Hampton, NH 03862 800-429-8615
OFFICE USE ONLY
When the submission is complete (including check):
Date stamp plans and letter
➢ Complete and attach Receipt
Copy File; Forward to Consultant
Enter on Log Sheet and Database
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
-row.l OF t\d t� -Z fI -i
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (A Repair ( ) Upgrade ( ) Abandon ( ) - )?Complete System ❑Individual Components
S�"Ccyt;�yi �l/�+-af ° L4t �f" �'P,�1`Y r �ul�t/'✓I-ti'�f
Location Owner's Name
4ap Parcel# Address
Lot# Telephone#
Installer's Name Designer's Name
Address q7C Address
Telephone# Telephone#
Type of Building: Lot Size q o i/q Sq.feet
Dwelling—No. of Bedrooms Garbage Grinder (PY6
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required) gpd Calculated design flow gpd Design flow provided 3-_�O gpd
Plan: Date 12/:)-d of 1-2, Number of sheets -�2- Revision Date
Title S wb-z-- 41, Leif 14 -41 § �Ivn 61
Description of Soil(s) 6 r L
Soil Evaluator Form No.0/1 F166-- Name of Soil Evaluator - � C�� Date of Evaluation ����
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersig g'ree s th ove described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu e s no tion until a Certificate of Compliance has been issued by the Board of Health.
Signe Date J�Z&XV
Inspe tion
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
TOWN OF NORTH ANDOVER
Office of COCV MUNT'T'Y DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSC 001:9 STREET; SLATE 2035
NC)R'EH ANDOVER.,MASSACHUSETTS 01845
978M8,9540- Phone
Susan )',Sawyer,REHS/RS 978.688,8476--FAX
Ptiblie Health Director E-NIAJ ile LiltlrcleF)t(iiltowr5t'�>�fno iliaatidover.cotn
4W EBSITE: lltt is/1 /www.townaofnorthLrulover.c(.)IiI
SEPTIC PLAN SUBMITTAL FORM RECEIVED
Date of Submission: - . 6 „_ A 3 MAY � 0 TO � u C)R,t8j Site Location: Lot 16-4 Saracusa Way s, �
Engineer:Christiansen & Sergi, Inc.
New Plans? Yes XX $225/Plan Check# 6.3 4, (includes I" submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes No XX
Local Upgrade Form Included? Yes No XX
Telephone#:978-373-0310 Fax#: 978-372-3960
E-mail: phil@csi-engr.com
Homeowner
Name:-G.M.Z. Realty Trust
Applicant: Green & Company, 11 Lafayette Rd, No Hampton, NH 03862 800-429-8615
OFFICE USE ONLY
When the submission is complete(including check):
➢ Date stamp plans and letter
Complete and attach Receipt
Copy File; Forward to Consultant
Enter on Log Sheet and Database
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