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HomeMy WebLinkAboutApplication - 45 WELLINGTON WAY 3/9/2016 i TOWN OF NORTH NDO 'E Office of COMMUNITY UNITY DEVELOP ENT AND SERVICES ES HEALTH DEPARTMENT 1600 OSC GOD Sl"'REEI'; SUF1' : 2'035 NO Tli ANDOVER, MASS ACIIUSE17S 01145 978,688.9540- Pilot 979.688.8476- FAX E-MAIL: lic,tltli(.Ic t.(cr,)noi-tlitin(�loverzrra.gov WEliS1"T°E: littl)://%v vvv.tiorthaaiclOvcrnia.�uv SEPTIC PLAN SUBMITTAL FORM Date of Submission: l Site Location: ..... RECEIVED x Engineer: g., �� . .. � „4"..... �9 .. F NORTH ANDOVER New Plans? Yes $i» �/Plan. Check# (includes 1st submissio 14,0" NT review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes "" No Local Upgrade Form Included? Yes No c` Telephone#: � 79 � W:"�" -> .� ':� � Fax#: E-mail: 1,"14-) '�0,271 Homeowner Name: .y .� .... OFFICE USE ONLY When the submission is complete (including check): ➢ ✓ Date stamp plans and letter ➢ I,/ Complete and attach Receipt ➢ ZCopy File; Forward to Consultant ➢ ice' Enter on Log Sheet and Database i I No. THE COMMONWEALTH OF MASSACHUSETTS FEE ARC OF HEALTH � 6aY ) OF NO/e774. �� ''"al APPLICATION F ISM SAL SYSTEM CONSTRUCT �P� Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - `JComplete System ❑� � C' t I vV �>��lV'1�C Oye CL�-�/,� Location -277 p'�r� t_�vner's�Is��� C/ /Parcel# �'I�/Cir� ��C% Lot# S �� Telephone#T Installer's Name Dasi r" Name J r 0 Address Address q f_ /to Telephone# Telephone# Type of Building: 14Z I Lot Size %21, In S feet Dwelling—No.of Bedrooms Garbage Grinder ( p b Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.require ) `� gpd Calculated design flow gpd Design flow provided gpd Plan: D e /4 Number of sheets �_ Revision Date Title eVm LIS — 4S Description of Soil(s) Soil Evaluator Form No./Ak ! fl,,- Name of Soil EvaluatorpliLL I lsewvvaluation 1 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE S and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �t Date _ —of Inspections FORM i - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Commonwealth of Massachusetts City/Town of North Andover Y. f P ercolation Test Form 12 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:When 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 5 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 11:20 am 1/13/2015 .1:00 pm Date Time Date Time Observation Hole# 7A 713 Depth of Perc 3011 3011 Start Pre-Soak 11:24 1:00 End Pre-Soak 11:39 1:15 Time at 12" 11:39 1:15 Time at 9" 11:40 1:17 1 Time at 6" 1:42 1:20 Time (9"-6") 2 min 2 min Rate(Min./Inch) <2 min/inch , 2 min/inch Test Passed: z Test Passed: Test Failed: ❑ Test Failed: ❑ Philip Christiansen Test Performed By: Isaac Rowe Witnessed By: Comments: t5form12.doc•06/03 Perc Test•Page 1 of 1 U o 06 Z) CL D Z Z (6 m m m CL E � o u ❑ ❑ z° Tv 0 o a a CL —1 m o 0 g❑ ° o a) 0 Lo o v m in tt� ro CL 00 v E �s Q cc` s ON d Z a CL C� c z L, o _ o ® o ® c p o E 0 (D _ ° CI.) Z c _ a N W n a) m Z m ❑ U) ° m > ❑ Q W € ro .- I iri U' E iii o c c D 0 Q a) g � m r- a c o �5 o O L a) 0 �.. cu a .�' :D z z z z ❑ ❑ ® ❑ ❑ L Q� U C ;4l as -W Cl. 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