HomeMy WebLinkAboutApplication - 38 WELLINGTON WAY 3/9/2016 q.
TOWN OF NORTH ANDOVER
Office of C(.. M UN "rY DEVELOPMENTAND SERN710ES
HEALTH DEPARTM ENT
1600 OSGOOD S E I E+:,E+;'V; SCJI E E 2035
N( R141 A.NDOVER, MASSACHUSETTS 01845
978.688.9540-Phone
978,6W8476- FAX
E-NAIL: lac<altlidept(yr,)raortlidatidoveriaaa.gcry
W I_I3�I.�,E: lattp:/I' �vw.cicn°tlba ncl�':xver•zt'a�t.�a v
SEPTIC PLAN SUBMITTAL
FORM RECEIVED
Date of Submission:
MWN OF NORTH ANDOVER
MA � ��
Site Location: "" '
�U
Engineer:
d
.� a
New Plans? Yes $`�5/Plan Check# (includes Is' submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes °''w,.. No
Local Upgrade Form Included. Yes No
Telephone#. j r 7 3' Fax M
E-mail: .
kj
Homeowner
Name:
OFFICE USE ONLY
When the submi sion 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 RE-CEIVE-D
' I'd W OF h),,)RX4. &K1DdVCK-,,— �i i� C H i,U1 i
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTj jF'VND0VER
HEALTH DEPARTMENT
Application for a Permit to Construct Repair Upgrade Abandon )4omplete System ❑Individual Components
,3 9 1 hvt- W—a-Y E5S71 U A D-&V&LD tv�44 PVI-
Location Owner's Name
C 41
277 WA,-S14-1N6W0 C-;7 6"11614k✓
Map[Parcel#
i - 9-?/ - -31Vr?)lep Lot# Te
1(6h,4�0,wA4 V---
Installer's Name Wrier's Na
Address A 3-1.3
Telephone# Telephone#
Type of Building: Lot Size
j 3 Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder
Other—Type of Building No.of persons Showerly Cafeteria
Other fixtures
Design Flow(min.required) gpd Calculated design flow
gpd, Design flow provided d
Plan: Date Number of sheets if Revision Date
Title 0 bEsiG iv t-al-1
Description of Soil(s) e-
Soil Evaluator Form No. ttA-12 Name of Soil Evaluator Abate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
hc/a/
A
Signed Date
Inspections
FORM 1 APPLICATION FOR DSCP DEP APPROVED FORM 5/96
Commonwealth of Massachusetts
City/Town of North Andover
RECEIVED
Percolation Test
Form 12 MA[ 1 () 2016
TOWN OF NORTH ANDOVER
Percolation test results must be submitted with the Soil Suitability Asses ent!icrOn-slte 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:When A
filling out forms A. Site Information
on the computer,
use only the tab Gordon Family Trust
key to move your Owner Name
cursor-do not 602 Boxford Street LOT I
use the return Street Address or Lot#
key.
North Andover MA 01845
City/Town State Zip Code
Philip Christiansen 978.373,0310
Contact Person(if different from Owner) Telephone Number
B. Test Results
1/13/2015 1:49 1/13/2015 2:30
Date Time Date Time
Observation Hole# 3-A 3-B
Depth of Perc 31 + 14 =45 4 + 17 =21
Start Pre-Soak 1:49 2:30
End Pre-Soak 2;04 2:45
Time at 12" 2:05 2:45
Time at 9" 2:30 3:07
Time at 6" 2:52 3:31
Time (9"-6") 22 .24
Rate (Min./inch) 8 min/inch 8 min/inch
Test Passed: z Test Passed: z
Philip Christiansen Test Failed: El Test Failed: El
Test Performed By:
Isaac Rowe
Witnessed By:
Comments:
t5form12.doc-06/03 Pere Test•Page 1 of 1
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