HomeMy WebLinkAboutSeptic Plan Submittal Form & Receipt - 9.21.2018 - Receipt - 50 SAW MILL ROAD 9/13/2019 TOWN OF NORTH ANDOVER
RECEIVED Community & Economic Development
HEALTH DEPARTMENT
SEP 2 2018 120 Main Street GO
NORTH ANDOVER,MASSACHUSETTS 01845
TOWN OF NORTH ANDUVER 978.688.9540—Phone
HEALTH DEPARTMENT 978.688.9542—FAX
E-MAIL:healthdept@northandoverma.gov
WEBSITE:http://www.northandovenna.gov
SEPTIC PLAN SUBMITTAL
FORM
Date of Submission: September 24, 2018
Site Location:50 Saw Mill Road
Engineer:Jack Sullivan, PE
New Plans? Yes X $275/Plan Check# (includes lst submission and one re-
review only)
Revised Plans?Yes $125/Plan Check#
Site Evaluation Forms Included? Yes X No
Local Upgrade Form Included? Yes X No
Telephone#:781-854-8644(Jack) Fax#:
E-mail:jacksu1153@comcast.net
Homeowner
Name: Mark and Heather LaRosa 781-799-2831
OFFICE USE ONLY
When the sub sion is complete(including check):
➢ Date stamp plans and letter
➢ L- Complete and attach Receipt
➢ Copy File; Forward to Consultant
➢ Enter on Log Sheet and Database
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CONTRACTOR NAME: 'Ja-r—/C . 011
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 S s�terns:
❑ Septic-Soil Testing $
' -
Septic-Design Approval
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
Healt Agent Initials
White-Applicant Yellow-Health Pink-Treasurer