HomeMy WebLinkAboutApplication - 17 LACY STREET 5/8/2007 VA
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�--'P�_.i CAT�ON FOR 01 L ����,
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�'� 1 �" MAP& PARCEL:
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LOCATION OF SOIL TESTS:
APPLICAN( `C�`�1;
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ADDRESS_.____
ENGINEER ,,,f�sC_ E�iI
cERI IFIFD SOIL EvALUAT OR:
Intended Useof Land: Resiclenfi l Sukxlivision Commercial
Is I I'd,,: Repair Undeveloped Lot T ing:_ Upgradefor Addition:
In fhe lake Co(.hichewick)Atatershed'? Wes
NO ,
THI F5I_L5WlNG MUST QF INCL U[�F.r�111F1 iI� THIS LORD!!
Proof of land ownership(Tay bill,or leffer from owner permitting test)
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11-Plot plan& Location of TF in ( Ic e indicate tcst�:it siteson the )Ian)'
Fee of 1 5S00pry lot for naryoom4ruction. This covers t lie minimum two deep holes and
two percoLafiontestsrequiredfor each disposal a(—A. Feeof¢360.00 per lot forLepairsor up rides
GENERAL INFORMATION
r Oi -,.tified Soil FwAuatorsmay pen-01 dKI.D hole inspei;tions.
Only 1111a�. Reclisic�ei�S�nitariansand Professio��al Fngira�rs cal d�gn 5�tic plans.
r Al lest two deep holes and two percolation test:;a-e reClui l(A for each SWic system disPosal area-
k Rep-A r rsqui re at leaf tvvo deep hol es aid d I cod one paj col ation tee:, at the discretion of the t3OH
FepreSAntativa
} f=ull payment will berequired for Al additionA 9:e�Aswithintwoweeksoftesing.
} \v1lifhin45daysofte-i sing,asr.aledplan(no,,�riallerthan'1 -100_)sliallbesubmittedtotheBoadofHe Ali
showi ng i fie l oc,,Y(i on of all i s(I nd udi ng aborts
k \A/ithin60daysofie~tingsoiIataluationformsshallbesubmitted-
Plenst:Do Not \Afl ite Bell avnJThi9 Line
N.A. Conservation Commission A.pproyal Date: fIGC
Signaiur2 of ConSvation Agent.
Late back to I lealth Depav meat: (stamp in)
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A =W une e S „ o Cara Laa n t requrrd nan
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NORTH APlDOVCR PLANNING BOARD ;I
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