HomeMy WebLinkAboutApplication - 80 PATTON LANE 9/28/2004 TOWN OF NORTH ANDOVER �wcr"ryrW�ti
Office of COMMUNITY Y DEVELOPMENT AND SERVICES
HE ALTH DEPARTMENT
27 CHARLES STREET °p
NORTH ANDOVER,MASSACHUSETTS 01845
Susan Y.Sawyer,REHS,RS 978.688.9540—P one
Public Health Director 978.688.9542—F �� �``�t' G PAt R FNI'' �t
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healthdept @town rfi �n°d�r:cbm �
www.townofiiorthandover.com
APPLICATION FOR SOIL TESTS
DATE: MAP&PARCEL: ti
LOCATION OF SOIL TESTS:
OWNER:
Contact#: d"q �°,
APPLICANT: µv "'"re Contact#:
ADDRESS: � i4'
ENGINEER: Contact#: t . „" 67
CERTIFIED SOIL EVALUATOR:
Intended Use of Land: Residential Subdivision Single Family H
orpe" Commercial
Is This: Repair Testing: Undeveloped Lot Testing: Upgrade for Addition:
In the Lake Cochichewick Watershed'? Yes No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
Proof of land ownership(Tax bill, or letter from owner permitting test)
8.5"x 11"Plot plait&Location of Testing(please indicate test pit sites ou the p1an2
�
Fee
wo percolation per
ests req med focanch disposal area.icFek,tsf w,OGppum two deep holes and
ut n
er lot for repairs or ttp�rades.
GENERAL INI'ORMATIO'
➢ Only Certified Soil Evaluators may perform deep hole inspections.
Only Mass.Registered Sanitarians and Professional Engineers can design septic plans.
Y At least two deep holes and two percolation tests are required for each septic system disposal area.
Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH
representative.
Full payment will be required for all additional tests within two weeks of testing.
Within 45 days of testing,a scaled plan(no smaller than 1"-100')shall be submitted to the Board of Health
showing the location of all tests(including aborted tests).
y Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval Dater_
Signature of Conservation Agent:
Date bark to Health Department: (stanip in):
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14P fax K1220xi Log for
NORTH ANDOVER
9786889542
Sep 28 2004 3:45pm
Last Transaction
Date Time Type Identification Duration Pages Result
Sep 28 3:40pm Fax Sent 819782820012 4:16 5 OK
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Commormealth of Massachusetts
City/Town
Percolation Test
Form
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. D P has provided this form for use by local Boards of I�-lealth. Other forms may be used, but
the information roust be substantially the same as that provided here, Before using this farm, check with
the local Board of Health to determine the form they use.
important: Site Information
When filling out
forms on the
computer,use Maark Palmer
only the tab key Owner Name
to move your 80 Patton Lane
cursor-do not _ --_- _----- _Address -_.-- ----.._ ---- _ -_--
use Street __ ___ . .
the return
Address or Lot# _ -----_
key. N. Andover MA 01845
City/"r own -, State --...
_ Zip Code
rmh (97939-973
Contact person if different from Owner - -- - Tele hone Number
roan p l ._....._._.._�__
6;
10/27/04 1t1 am
- ...__.._.._..._..- - - _... __----._..._ _..-. ----------- ...............................-
Cate Time Date Time
Observation Hole# P-1
Depth of Pere
Sr aStart Pre;-soak 9:35 AM ............... - --
End Pre-Soak 9:50 AM
"rime;at 12" 9:50 AM
"rime at 9,, 9_52 AM
Time at "Time (914)) -------------- _..... ....._.._ _._..._ ------- - - -
Pate (Min./Inch) � 2 MItV/11V.
Test fussed: El Test Massed: ILI
"rest Failed: Test Failed:
James Kavanaugh
Test performed Icy:
Dill River Consultants
Witnessed key: __...
Comments:
t5form12.doc-06/03 perc Test®page 1 of 1
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