HomeMy WebLinkAbout- Miscellaneous - 1015 FOREST STREET 2/13/2019 e
TOWN OF OR I"fit ANDOVER /f
C"onit"Imit° ^ & P"Conomic Development
HEALN11 DEPARTMENT
120 Main Street
et
N(.)1011 NDOVI R, 1' ASSA(;l-It.1SL,"I,,[;' 01845
97&688,9540 Phone
978.6M9542- FAX
E.-MAIL: lt(,altlidel)t(erbnoill,ia idovei iri�i,gov
M!EBSI 4 t,: tts/lwmy.nor14itlmr4doy xNr aaw. ,cry
SEPTIC, FLAN SUBMITTAL
FORM IRPECEWED
Date ofSubmission: December 13, 2018
TOWN OF NF:lF.I.&oANDOVER
Site Location: 1015 Forest Street(Tax Map 105D Lot 56) HEAL111 Fa h'"/dfl MENT
Engineer: Jack Sullivan, PE
New Plans? Yes._X__.___$275/Flan Check.# (includes 1" submission and one re-
review only)
Revised I"lans?Yes $125/flan Check#f
Site Evaluation Forms Included? Yes X No
Local Upgrade Form Included? Yes X No
Telephone#.:781-854-8644 Fax#i:
E-mail: jacksuI153@acom cast.not
Homeowner
Name: Steve Cunha
OFFICE USE ONLY
When the , nission is complete (including check):
Date stamp plans and letter
Complete and attach Receipt
Y � Copy File; Forward to Consultant
Enter on Log Sheet and Database
Town of North Andover
sgcNus
HEALTH DEPARTMENT
CHECK#:
DATE:
LOCATION �,�
...........
..
CONTRACTOR NAME: ...........
Type of Perinit or,License: (Check box)
0 Animal
• Body Art Establishment
• Body Art Practitioner
0 Dunipster
• Food Service-Type:--
• Funeral Directors
• Massage Establishment
• Massage Practice $
• Offal(Septic)Hauler $
• Recreational Camp
• Sun tanning
• Swimming Pool $
[I Tobacco $-
0 Trash/Solid Waste Hauler $
0 Well Construction $
SEPTIC sLeni
0 Septic-Soil Testing
Septic-Design Approval $
* Septic Disposal Works Construction(DWC) $
* Septic Disposal Works Installers(DWI)
* Title 5 Inspector
0 Title 5 Report
0 Other. (Indicate)-----
H"'dlth'Agent Initials
e
White-Applicant Yellow-Health Pink-Treasurer