HomeMy WebLinkAboutPlan Submittal Form - Receipt - 1985 SALEM STREET 9/25/2019 TOWN OF NORTH ANDOVER
Community & Economic Development
HEALTH DEPARTMENT
120 Main Street 40
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 Location: AIL IF M 57 C-D ? 2S
Engineer: Qf R7572/1IVSi M /11vU Sj9/Z6-7j A/C,
New Plans? Yes l/ $275/111nn Check # (includes I" Submission and one re-
review only) �O
Revised Plans?Yes $125/Plan Check#
Site Evaluation Forms Included? Yes__V No
Local Upgrade Form Included? Yes _ No
Telephone#: !�715 37 7 0310 Fax#:
E-mail: —I-'J 6)CS 1 — E NG-K. QO
Homeowner
Name: L I V7 lvty-S Za r la p i v aG-O D.M t=N( CORP.
OFFICE USE ONLY
When the5�ssion is complete(including check):
Date stamp plans and letter
➢ Complete and attach Receipt °
➢ Copy File;Forward to Consultant
1
➢ _� Enter on Log Sheet and Database
i
NORTH / / V O
O D
Town of North Andover
HEALTH DEPARTMENT
,SSACHus�'�
CHECK#: DATE: +�-tq
LOCATION: 7 S
H/O NAME: r1.0 �.0
CONTRACTOR NAME: o � Ito
Type of Permit or Licens : (Check box) n �o a5
❑ Animal $ N
❑ Body Art Establishment
Art Practitioner $ 1
❑ Body / 5
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
I
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ RecreationaI Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
I
SEPTIC Systems
❑ Septic-Soil Testing $
i X Septic-Design Approval
t
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other: (Indicate) $
ealth Agent Initiai
White-Applicant Yellow-Health Pink-Treasures