HomeMy WebLinkAboutApplication - 46 STANTON WAY 5/3/2013 TOWN OF NORTH ANDOVER
Office of COMMUNITY Dlt;V.CL OP1' I+NT A:ND SERVICES
11 E.M.T 1 DEPARTMENT
1600 OSC:OOD STREET; SLATE 2035
NORT14 AND(WER, MASSACII(.JSITI"IS 01845
978.688.9540 Phone
Susan Y.Sawyer,RE11SAIS 9 75.6M8476 FAX
Public Health 'Director E-MAIL:Iiealttide)u�i)towtioft ortli�Aii(lc)ver.cot77.
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SEPTIC PLAN SUBMITTAL FORM
Date of Submission: ,-a , /._& /25
Site Location: Lot 31 Saracusa Way
Engineer:Christiansen & Sergi, Inc.
New Plans? Yes XX $225/Plan Check# (includes Is' 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
csi-engr.com
Homeowner
Name:SPEC 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
r Copy File; Forward to Consultant
r Enter on Log Sheet and Database CEIV"ED
TO WA ,j�.ka e��t�i.�t t H AIhAk0 5�`P:IT
R IU_f�E k hl k�lw�l";��I�KIVI�111"'I`
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
17,101 - OF r\.FOR?(a AN O d i1 E 12-
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ('') Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components
LOT 31 5/ak'A Ct6 A Wft-/
Location Owner's N me
3 - 3 / 1
1AFfiY&-[F6 !2t). 1U 11,W 't 01,01 63862-
Map/Parcel# Address
Lot# Telephone#
c_i+Ri snA&&eW f S EP,61 /AA-
Installer's Name Designer's Name
lbc) 511MWEIZ Sr f-fRV;`KWLZ . MA 0(5,.3 6
Address (J Address
Telephone# Telephone#
Type of Building: 5e WC,tF_ PAM IL-/ Lot Size 47, 7&2� Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder (0�
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.re uired) q4b gpd Calculated design flow gpd Design flow provided 0�6 gpd
Plan: Date 3D 43 _ Number of sheets ,?- Revision Date
Title SEP-M S 45 iFM I)Ef;!6!®/ /W' UT 3/ SA&WS19 W6 y. V iq
Description of Soil(s) FS - A45 _
Soil Evaluator Form No. ®N FIL4C Name of Soil EvaluatorD Padearne,lle_�' Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agr es ins I e above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furth o n-operation until a Certificate of Compliance has been issue by_the,.Board of Health.
a ,t
Signed Date
Inspec ons
I' .' ,ji r.i1 J I
_ �n rii �I lid El I n�ti �a r,ii
FORM I — APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96