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Home My WebLink AboutMiscellaneous - 45 WELLINGTON WAY 4/30/2018 (2)fl ,r L" �� tis Wil vJo_� Town wm of North Andover — Septic System - AS -BUILT CHECKLIST T ll changes to the design plan have been reflected and noted on the as -built plan s -built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans) JStreet Address, Assessor's Map and Lot Number JLot Lines and Location of Dwellings served by the system cations, Elevations and Dimensions of As -built system components, including reserve (if applicable) Ties to all tank openings, d -box, and leach area from dwelling or Permanent Structure Setback distances are shown on the as -built plan from system components to: Subsurface, interceptor & foundation drains X Catch basins �_Property lines Dwellings or other structures Private water supply or irrigation wells V Watercourses or wetlands Locations of Wel Drains, etland Resource Areas within 150 feet of system v Location of water, gas, electric lines, cable, control panel (if applicable) Location of Structures within 6 Inches of Finished Grade Original Stamp & Signature Location and holder of any easements which could impact the system Impervious Areas; Driveways, etc v North Arrow V Location & Elevation of Benchmark used STATEMENT ON PLAN (NA 5.3) a. "I certify the locations, elevations, ties, cover material; exposed component covers etc., shown on this as -built substantially agree with the approved plan and have determined that the break out elevations, if applicable, have been met." Signature of Designer Date b. "If a STUCTURAL WALL IS PRESENT W 4.9) a Letter or statement on the as -built indicatmz the wall - wasz or was not, constructed in accordance with the intended design and any manufacturer's specif cations." Signature of Designer Date As of: Tuesday, March 17, 2015 PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: October 18, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: New System On -Site Sewage Disposal System By: Dave Maynard At: 45 Wellington Way Map lOS.0 Lot 88 Aj ,h Andover, MA 01845 of this certifica� �6hal not be construed as a guarantee that the system will function satisfactorily. MiEhe1& E. Grant Public Health Inspector 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov 41 . . .,��Ars. • Commonwealth of Massachusetts Map -Block -Lot .• �� BOARD OF HEALTH �® Permit No North Andover BHP -2017-0540 ------ ._, P.I. �` FEE rus F.I. '0 $350.00 DISPOSAL WORKS CONSTRUCTION PER avea Permission is hereby granted ___D__M___ ynand _ __ �- to (Construct) an Individual Sewage Disposal System. at No 45 WELLINGTON WAY -------------------------------------------------------------------------------------------------B------- as shown on the application for Disposal Works Construction Permit No. HP -2017-0 ated to er 017 -------------------------- --------------------------- ----- Issued On: Sep -06-2017 BOARD OF HEALTH (R V Application for Septic Disposal System Construction Permit — TOWN OF NORTH ANDOVER, MA 01845 TODAY'S DATE $350.00 - Full Repair $175.00 - Component Important: Application is herebV made fora permit to: CF. When filling out Construct a new on-site sewage disposal system* VV forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* SEP 0 6.2017 only the tab key to move your El Repair or replace an existing system component— What? ANO� �� cursor - do not use the return A. Facility Information 10V NO H�1,THDEP key. / J t1_S �J` ecs� 4"'A 7� iC I Address or Lot # rad ✓r i1± 7/7a� V' City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump 0,Gravity.(choose one) ***If pump system, attach copy of electrical permit to application*** ➢ ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) - - --� -- ➢�=❑:Pressure- Dosed-(D=Box-Present):S-.A-.S. — - — _ - — - M ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) Wbatis the Make? What is the Model.? 2. Owner Information ._, Name / V Addr�esps (if di erent rom above) City/Town State Zip Code cn,y 4e 9,7y F-'37 - ?,, 3 Email address Telephone Number Installer Information ��/y `�-C /'�.r-� L-+i.� -ems (Y / l.'�—r y+./► -"t- �/ � cc.:��..'�e�..-� l"e Name j% Name of Company Address City/Town State Zip Code 5727 3;> s - 2 2zF Telephone Number (Cell Phone # if possible please) 4. Designer Information Name, yy��JJ r ress Name of Company City/Town e-.,- A, mate Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Y . "o "" ,�-a�• Application for Septic Disposal System Construction Permit —TOWN OF NORTH .ANDOVER, MA 01845 PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: residential Dwelling or ❑Commercial B. Agreement TODAY'S DATE $350.00 - Full Repair $175.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. Name 11, Date tplication Appr a y: (Boar of Health Representative) Nam Date Application Disapproved for the following reasons: For Office Use Only: �. Z Fee Attached. Yes No 2. Project Manager Obligation Form Attached. 3. Pump System? If so, Attach copy of Electrical Permit Applicantreceived copy of "Electrical Inspection Notes for Septic Systems" Handout? 4. Reviewed approval letter, all paperwork received.? 5. Foundation As -Built? (new construction only): (Same scale as approved plan) YesL/ No Yes NoJZ1 res "T_ ZYes No Yes No 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic systeA< For plans by &/// e! G& -e c— (Engineer) Relative to the application of�t— (Installer's naISCE V GD And dated Z — 19 ^ 26/ (Original ate Dated �— 2,017 SEP 0 6.2017 (I'odays ate With revisions dated 3 — .2y -- Zd I % 1p4NN OF NORTH ANDOVER (Last revised date) HEALTH DEPARTMENT I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the apbroT ved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed – Generally, this is the first (1'� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection – Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@northandoverma.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade - Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board ofHealth staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. As the installer, I understand that I am soldy responsible for the installation of the system as per the approved plans. No instructions by the homeowner. Lyeneral contractor. or anv other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: ��-1,�-e/%•4,:_, c_�/ (Today's Date) 7— 6e 26/1_2 (Name –Signed) Ot NORTM 7998 Town of North Andover `�'•�,; o �: HEALTH DEPARTMENT - 1SS�CNU`'fl CHECK #: A/ DATE: 9 64I—� LOCATION: 11/) GTn a ? H/O NAME:. t! CONTRACTOR NAME• d-�GC TYye of Permit or License: (Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massa`ge Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool F . $ ❑ Tobacco ,f $ ❑ Trash/Solid Waste Hauler {4 $ 7 ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ Septic Disposal Works Construction (DWC) s3.50 ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Hea gent Initials White - Applicant Yellow - Health Pink - Treasurer of NORry qti o p NNE � ca `SSA C HUs�� North Andover Health Department (ommunity and Economic Development Division April 6, 2017 Messina Development Corp 277 Washington Street Groveland, MA 01834 Re: Subsurface Sewage Disposal System Plan for 45 Wellington Way = Lot 5 (Map 105C, Lot 88) To Whom It May Concern: The proposed wastewater system design plan for the above site dated February 22, 2016 with a final revision date of March 24, 2017 and received onApril 6, 2017 has been approved. The design has been approved for use in the construction of a new on-site septic system for a 4 - bedroom (max 9 -room) home utilizing a gravity leach field system. This design plan approval is valid until April 6, 2020. During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. This approval is also subject to the following conditions: 1. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit a foundation as -built at the same scale as the approved plan 2. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit the floor plans of the proposed dwelling showing no greater than 4 bedrooms or a total of 9 rooms. North Andover Health Department, Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Page 1 of 2 Fax: 978.688. 9542 45 Wellington Way April 6, 2017 3. — If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit'is void; installation shall stop, and the applicant shall reapply for a new 'Disposal Systems Construction Permit (310 CMR 15.020(1)). 4. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation ` Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector +� and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely, ?ria,�J. LaGrasse, CEHT Director of Public Health Encl. Installers list cc: Philip Christiansen, P.E. File Page 2 of 2 North Andover Health Department, Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688. 9542 North Andover Health Department (ommunity and Economic Development Division April 6, 2017 Messina Development Corp 277 Washington Street Groveland, MA 01834 Re: Subsurface Sewage Disposal System Plan for 45 Wellington Way — Lot 5 (Map 105C, Lot 88) To Whom It May Concern: The proposed wastewater system design plan for the above site dated February 22, 2016 with a final revision date of March 24, 2017 and received on April 6, 2017 has been approved. The design has been approved for use in the construction of a new on-site septic system for a 4 - bedroom (max 9 -room) home utilizing a gravity leach field system. This design plan approval is valid until April 6, 2020. During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. This approval is also subject to the following conditions: 1. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit a foundation .as -built at the same scale as the approved plan 2. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit the floor plans of the proposed dwelling showing no greater than 4 bedrooms or a total of 9 rooms. Page 1 of 2 North Andover Health Department, Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688. 9542 45 Wellington Way April 6, 2017 3. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit (3 10 CMR 15.020(1)). 4. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely, Fn rian. LaGrasse, CEHT Director of Public Health Encl. Installers list cc: Philip Christiansen, P.E. File Page 2 of 2 North Andover Health Department, Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688. 9542- 46 PUBLIC HEALTH DEPARTMENT Community & Economic Development TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; ( ) repaired; By: Dave Maynard (Print Name) Located at: 45 Wellington Way (Lot 5 Wellington Woods) (Installation Address) Was installed in conformance'with the North Andover Board of Health approved plan, originally dated 2/19/16 and last revised on 3/24/17 , with a design flow of 440 gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: 9/11/17 Pfil Christiansen, P.E. And — Print Name Final Construction Inspection Date: 9/19/17 Phil Christiansen. P.E. And — Print Name Installer: (Signature) En ' eer Representative (Signature) Date: Phil Christiansen. P.E. And — Print Name Date: l And — Print Name 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (constructed; ( ) repaired; �Kmt Name) / Located at: Was installed in conformance with the North Andover Board of Health approved plan, originally dated 21114, and last revised on 2017 with a design flow of �YV6 gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: Engineer Representative (Signature) And — Print Name Final Construction Inspection Date: Engineer Representative (Signature) And — Print Name Installer (Signature) Date: And — Print Name Engineer: (Signature) Date: And — Print Name 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov >4 North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 45 Wellington Way Lot 5 MAP: 105.0 LOT: 88 INSTALLER: Dave Maynard DESIGNER: Christiansen and Sergi PLAN DATE: February 22, 2016 BOH APPROVAL DATE ON PLAN: April 6, 2017 INSPECTIONS TANK INSPECTION: 9/12/2017 DATE OF BED BOTTOM INSPECTION: 9/12/2017 DATE OF FINAL CONSTRUCTION INSPECTION: 9/22/2017 DATE OF FINAL GRADE INSPECTION: 10/11/2017 SITE CONDITIONS Comments: Mill River SEPTIC TANK ® Contractor reports any changes to design plan N/A Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered ® Building sewer in continuous grade, on compacted firm base N/A Cleanouts per plan ® Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ® Monolithic tank construction ® Water tightness of tank has been achieved by visual testing ® Inlet tee installed, centered under access port Outlet tee installed, centered under access port 1 (gas baffle/effluent filter) 24 inch cover to finish grade infinish grade installed over access port ® Neoprene boots around & outlet Comments: 9/12/2017 B. LaGrasse 9/22/2017 Mill River DISTRIBUTION -BOX ® Installed on stable stone base ® H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: M. Grant SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan ® 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan N/A Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: 9/12/17 39'x 36' B. LaGrasse FINAL GRADE ® Loamed ® Seeded ® Cover per plan Comments: M. Grant DOCUMENTS NEEDED ® Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ® As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws SEPTIC PLAN SUBMITTAL FORM Date of Submission: � z' O 7 Site Location: fS w ell, iq� Engineer: . rlS7 "S r n New Plans? Yes. review only) Revised Plans?Yes $275/Plan Check # $125/Plan Check # Site Evaluation Forms Included? Yes No. Local Upgrade Form Included? Yes No. Telephone #: Fax E-mail: Homeowner Name: A_<s % n q==. OFFICE USE ONLY When the submission is complete (including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database 978.688.9540 — Phone 978.688.9542— FAX E-MAIL: healthdept@northandoverma.gov WEBSITE: http://www.northandoverma.pov .(includes 1St submission and one re- asR f� t TOWN OF NORTH ANDOVER SEPTIC PLAN SUBMITTAL FORM Date of Submission: � z' O 7 Site Location: fS w ell, iq� Engineer: . rlS7 "S r n New Plans? Yes. review only) Revised Plans?Yes $275/Plan Check # $125/Plan Check # Site Evaluation Forms Included? Yes No. Local Upgrade Form Included? Yes No. Telephone #: Fax E-mail: Homeowner Name: A_<s % n q==. OFFICE USE ONLY When the submission is complete (including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database 978.688.9540 — Phone 978.688.9542— FAX E-MAIL: healthdept@northandoverma.gov WEBSITE: http://www.northandoverma.pov .(includes 1St submission and one re- TOWN OF NORTH ANDOVER Community & Economic Development HEALTH DEPARTMENT �- 120 Main Street NORTH ANDOVER, MASSACHUSETTS 01845 SEPTIC PLAN SUBMITTAL FORM Date of Submission: � z' O 7 Site Location: fS w ell, iq� Engineer: . rlS7 "S r n New Plans? Yes. review only) Revised Plans?Yes $275/Plan Check # $125/Plan Check # Site Evaluation Forms Included? Yes No. Local Upgrade Form Included? Yes No. Telephone #: Fax E-mail: Homeowner Name: A_<s % n q==. OFFICE USE ONLY When the submission is complete (including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database 978.688.9540 — Phone 978.688.9542— FAX E-MAIL: healthdept@northandoverma.gov WEBSITE: http://www.northandoverma.pov .(includes 1St submission and one re- TOWN OF NORTH ANDOVER Community & Economic Development HEALTH DEPARTMENT, 120 Main Street NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 — Phone 978.688.9542— FAX E-MAIL: healthdept@northandoverma.gov WEBSITE: http://www.northandoverma.gov SEPTIC PLAN SUBMITTAL FORM Date of Submission: Site Engi New Plans? Yes $275/Plan Check # (includes lst submission and one re- review only) ,"v Revised Plans?Yes $125/Plan Check # Site Evaluation Forms? 6`D CS ! included .. Yes No 1�8� Local Upgrade Form Included? Yes No n//ff Telephone #: L?�-3 73 6 lU Fax #: E-mail: 1-4 Homeowner n� Nacre: OFFICE USE ONLY When the submission is complete (including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt ➢ Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database \i ...�, n N o, 4„oR; . 7 7 b 5 .o .o Town of North Andover HEALTH DEPARTMENT ,SSACMU`+�t f CHECK #: t DATE fl7 LOCATION: zo H/O NAME: --- CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: } � 0-5 -5)blow . j❑ Septic -Soil Testing ✓�J ❑ Septic - Design Approval $� ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ V ❑ Other: (Indicate) $ A An Health Agen nitials White - Applicant Yellow - Health fink - Treasurer