HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 300 FOSTER STREET 7/2/2020 TOWN OF NORTH ANDOVER
Community & Economic Development
HEALTH DEPARTMENT
120 Main Street 4D
NORTH ANDOVER, MASSACHUSETTS 01845
978.688.9540—Phone
978.688.9542—FAX
E-MAIL:healthdept@northandoverma.gov
WEBSITE:http://www.northandovermagov
SEPTIC PLAN SUBMITTAL
FORM
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Date of Submission: Dec. 12, 2019 T 1 F OF, �
Site Location: 300 Foster Street C0F4'Q T��019
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Engineer: Jack Sullivan, PE
New Plans? Yes x $275/Plan Check# 9494 (includes I"submission and one re-
review only)
Revised Plans?Yes $125/Plan Check#
Site Evaluation Forms Included? Yes No x !�r
Local Upgrade Form Included? Yes No x
Telephone#: 781-854-8644 (engineer) Fax#:
E-mail: jacksull53@comcast.net /
Homeowner
Name: Dipti Shah
OFFICE USE ONLY
When the ssion is complete (including check):
➢ Date stamp plans and letter
➢ Complete and attach Receipt
➢ Copy File; Forward to Consultant
➢ _ Enter on Log Sheet and Database
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Town of North Andover
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CHECK#: 9 DATE: •��.�p�9
LOCATION: 300
H/O NAME: )
CONTRACTOR NAME: Jp j/ 4
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 Systems:
❑ Septic-Soil Testing $
Septic-Design Approval —
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
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Hea-Ith Agent Initials
White-Applicant Yell-Health Pink- Treasurer