HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 1 PENNI LANE 11/20/2019 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:htti):Hwww.northandovert-na.a-ov
SEPTIC PLAN SUBMITTAL
FORM
Date of Submission.
Site Location: toe^'S.1 I
Engineer: 4 VJ,.%, V I
New Plans? Yes V"/$275/Plan Check# (includes I"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#: '77d' 37f T),P/ Fax #: 7 J'
E-mail:— k, ✓1'4 V11 4
Homeowner
Name:
OFFICE USE ONLY
When the sub sion is complete(including check):
>
Date stamp plans and letter
> Complete and attach Receipt
>
Copy File; Forward to Consultant
> V Enter on Log Sheet and Database
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` Town of North Andover
",, -••,„o,;.=�,' HEALTH DEPARTMENT
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CHECK#: DATE: !S_��1 J
LOCATION: n�• '� ��
H/O NAME: �4 CIf
CONTRACTOR NAME: 71
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 $---
SEEp(:S su tems:
❑ Septic-Soil Testing $---
i Septic-Design Approval $ s I
1 \ 1
❑ Septic Disposal Works Construction(DWC) $----
❑ Septic Disposal Works Installers(DWI) $----
❑ Title 5 Inspector $—"--
❑ Title 5 Report $
❑ Other. (Indicate) $--
Ai7alth Agent Initials
White-Applicant fellow-Health Pink-Treasurer