HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 1975 SALEM STREET 8/31/2020 I
TOWN OF NORTH ANDOVER
Community& Economic Development I
HEALTH DEPARTMENT
120 Main Street
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 I
i
t
Date of Submission:
3
Site Location: 1975 Salem Street(Lot 3)
Engineer:Christiansen and Sergi, Inc.
New Plans? Yes X $275/Plan Check # (includes 1st submission and one rc-
review only)
Revised Plans?Yes $125/Plan Check#
Site Evaluation Forms Included? Yes X No
Local Upgrade Form Included? Yes _ No X
Telephone #:978 373 0310 Fax #:
E-mail:TJ@Csi-engr.com
Homeowner
Name:Livingstone Development, LLC
OFFICE USE, ONLY
When the sub 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
f 8 49
Ot MOPi'M,,'1'
a
Town of North Andover
HEALTH DEPARTMENT
,SSAC HUs�� `J
CHECK#: 7 DATE: 0/7
LOCATION: S yy .3
H/O NAME:
CONTRACTOR NAME:C'
' /ct 3"
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Durnpster $
❑ 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 $ a 7S_
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
Other. (Indicate) AUJ $
0 J/
Health-Agent Initials
White-Applicant Yellow-Health Pink-Treasurer