HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 1975 SALEM STREET 7/6/2020 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:heaithdept@northandoverma.gov
WEBSITE: http://www.northandoverma.gov
SEPTIC PLAN SUBMITTAL
FORM
0000
Date of Submission: - - oZ co `7 R C� �93
Site Location: j j'V $ALt M S T LOT 1 �o�No�(NO�pP
Nam"
Engineer: H R 7S"P 1AM A niu SE RCrZ 7/VL.
New Plans? Yes_S,,$275/Plan Check# .a` _(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#: 6 73' __373 O 3 j 0 Fax#:
E-mail: ?J C. 2—k Aff,R
Homeowner
Name: Z UZrvCYS?c Nl3 t_0 PM t�/y T
OFFICE USE ONLY
When the_uiby4ission 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
O,4NOR rM 1y 7900
�O
1O: L..• ,� 09
Town of North Andover
�+, •.,.,,.: ,' HEALTH DEPARTMENT
,SSACM�Stt
CHECK#: /b l7 DATE: -02017
LOCATION: -25ZJe/n 6'y1`:V
H/O NAME: a.e e, 4o iQ
CONTRACTOR NAME:
a �
Type of Permit or Licens : (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-
13
Septic-Soil Testing $
x
Septic-Design Approval $❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
f -
f ealth Agent Initials
White-Applicant Yellow-Health Pink- Treasurer