HomeMy WebLinkAboutMiscellaneous - 851 FOREST STREET 7/18/2018 (2) TOWN OF NORTH ANDOVER
Community & Economic Development
HEALTH DEPAR'T'MENT
1.20 Main Street
NORTH ANDOVER, MASSACHtTSETTS 01845
978.688.9540—Phone
978.688.9542 FAX
E-MAIL:liealthdel)t@noilliandoveiiiia.gov
WEBSITE:halo://www.northandoverma. oovv
SEPTIC PLAN SUBMITTAL
FORM
Date of Submission: ....
Site Location: '
Engineer:-----
New
n sneer:_______New flans? Yes $275/Plan Check# (includes 1st submission and one re-
review only)
Revised Plans?Yes ° $125/Plan Check#
Site Evaluation Forms Included? Yes No
Local Upgrade Form Included? Yes __ No
Telephone#: '1 ),? -�' ) ( �/"l ),(,/ Fax #:
F.,-mail: X4d/ ,„� a /7� )P_
Homeowner
Name: :.
OFFICE USE ONLY
When the,&ubission is complete (including check):
° Date stamp plans and letter
➢ Complete and attach Receipt
Copy File; Forward to Consultant
Y Enter on Log Sheet and Database
T 59
ti Town of North Andover
HEALTH DEPARTMENT
CHU
CHECK#:
DATE: /13
LOCATION:
H/O NAME:
m(e,
CONTRACTOR NAME:
Type of Permit or License: (Check box)
0 Animal $
0 Body Art Establishment $
0 Body Art Practitioner $
0 Dempster $
0 Food Service-,Type:
0 Funeral Directors
0 Massage Establishment $
0 Massage Practice $
0 Offal(Septic)Hauler
IJ Recreational Cainp
0 Sun tanning $
0 Swimming Pool $-
0 Tobacco $
p' 0 Trash/Solid Waste Hauler $--
0 Well Construction $
SEPTIC Systems:
13 Septic-Soil Testing 5 o)b $
Septic-Design Approval $z,,-.,
0 Septic Disposal Works Construction(DWC) $
13 Septic Disposal Works Installers(DWI) $
0 Title 5 Inspector $
11 Title 5 Report $
11 Other. (Indicate)--- $
Health Agent Initials
White-Applicant Yellow,w-Health Pink- Treasurer