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HomeMy WebLinkAboutApplication - 51 WELLINGTON WAY 3/9/2016 TOWN OF" I ORT1I ANDOVER iii%//a/%� '• ::efface of CO MIJNITY DEVELOPMENTAND SERVICES HEA T ff DEPARTMENT 1600 OSGOOD S'f EET; SUITE 2035 NOR111 ANDOVER., MASSA01I1SETTS 01145 978.688.9540--Phone 978,688.8476--.. FAX E-MAIL: tacalttidept(c6,,tioi-tliarl(iove;rr7a�.gov WE BSITE : 17tti)://wxvtiv.nortliaat(:iov��ov SEPTIC PLAN SUBMITTAL FORM RRECEIVED Date of Submission: .3 f' Site Location: , :. f Ll S )VER t I ZNT Engineer: n New Plans? Yes � $ P lan Check# (includes 1St submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes °"""" No Local Upgrade Form Included? Yes No Telephone#: c 3 Q 6 Fax#: E-mail: Homeowner Name OFFICE USE ONLY When the submission is complete (including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt ➢ L,�O Copy File; Forward to Consultant ➢ 1�°° Enter on Log Sheet and Database No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH 2112 `ia a OF ) .i ., L—) b,) /...,)J (�� , APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PE T Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - omplete System ❑Individual Components I we l l i r vL W ocation Ow Name Map/ arcel# ,9-1g, ` s Tess C Lot# Telephone# (:::— Installer's Name 0 Sam es s m f a f Address r /l ?q 33 ! ress qi °J ( -- Telephone# Telephone# Type of Building: 4 Lot Si d Sq.feet Dwelling—No.of Bedrooms Garbage drinde (4z Other—Type of Building No, of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.re uir d) ° gpd Calculated design flow gpd Design flow provided pd Ilan: Date Number of sheets Revision Date Title Descrip ion of Soils) f A. Soil Evaluator Form No. It t- dam. Name of Soil Evaluator t r" UOqluation 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 an her agrees not to place the system in operation until a Certificate of Compliance has been issuel by the Board of Health. LCSigned Date h. Inspections TOWN OF NORTH ANDOVER FORM t - APPLICATION FOR DSCP ®EP APPROVED FORM 5/96 HEALTH Commonwealth of Massachusetts City/Town of North Andover REC-" Percolation Test Form 12 TOWN Percolation test results must be submitted with the Soil Suitability Assessment fo I 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 V k with the local Board of Health to determine the form they use. ftdOED Important:When A filling out forms Site Information MAI? �j 0 on the computer, use only the tab Gordon family Trust key to move your Owner Name TONq EF N""D VFA cursor-do not 602 Boxford Street LOT 4 HEALTH DEPAKMEONT use the return Street Address or Lot# key. North Andover MA 01845 ,14 IQ City/Town State Zip Code Philip Christiansen 978.373.0310 Contact Person(if different from Owner) Telephone Number B. Test Results 1/13/2015 1:40 1/13/2015 1:50 Date Time Date Time Observation Hole# 6A 6B Depth of Perc 4611 4611 Start Pre-Soak 1:40 1:50 End Pre-Soak 1:55 2:05 Time at 12" would not would not Time at 9" maintain maintain Time at 6" water level water level Time(9"-6") Rate (Min./Inch) <2 min/inch <2 min/inch Test Passed: z Test Passed: z Test Failed: ❑ Test Failed: ❑ Philip Christiansen Test Performed By: Isaac Rowe Witnessed By: Comments: t5form12.doc•06/03 Perc Test•Page 1 of I 00 > -n g p 0 0 > -n G) cp cn p cn 9 z cn 0) 0 G) -n A 3 c 2. > 0 go 0 2) =r 0 0 a - N3 q 0 =r ;:;: 0� 3- ' z Z (D (D < 0 3 0 (D a) CD CL 0 0 0 Q. 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