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Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 5 - Order of Conditions
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. General Information
From.
1. Conservation_ Commission
2. This issuance is for (check one): ® Order of Conditions ❑ Amended Order of Conditions
North Andover
DEP File Number:
242-1255
3. To: Applicant:
Joseph
a. First Name
65 Federal Sreet
Casey
b. Last Name c. Company
d. Mailing Address
Wilmington
e. City/Town
4. Property Owner (if different from applicant):
MA'.
f. State
01887
g. Zip Code
a. First Name b. Last Name
c. Company
d. Mailing Address
89
e. City/Town
f. State g. Zip Code
5. Project Location:
? ' 4 2Y A y
b. Date
2177 Turnpike Street
North Andover
a. Street Address
b. City/Town
Map 108.0
Lot 66
c. Assessors Map/Plat Number
d. Parcel/Lot Number
Latitude and Longitude, if known (note:
Joseph J. Serwatke, P. E.
electronic filers will click for GIS locator):
e. Latitude f. Longitude
6. Property recorded at the Registry of Deeds for
(attach additional information if more than one parcel):
Essex North
d. wunry
b. Certificate (if registered land)
6272
89
c. Book
d. Page
7. Dates: 5/11/04
a. Date Notice of Intent Filed
? ' 4 2Y A y
b. Date
Public Hearing Closed c. Date of Issuance
8. Final Approved Plans and Other Documents (attach additional plan or document references
needed):
as
Sewage Disposal System Site Plan and Profile
a. Plan Title
Joseph J. Serwatka
Joseph J. Serwatke, P. E.
b. Prepared By
c. Signed and Stamped by
5/8/04
1" = 20'
d. Final Revision Date
f. Additional Plan or Document Title
9. Total WPA Fee Paid: $ 250.00
a. Total Fee Paid
e. Scale
b. State Fee Paid
g. Date
c. City/Town Fee Paid
wpaform5.doc • rev. 6/9/04
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