HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 469 BOSTON STREET 4/14/2019 'r so
• 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:http://www.northandovenna.gov
SEPTIC PLAN SUBMITTAL
FORM '��''
Date of Submission: A 14Lo 1yu
Site Location: S' Qr ew
Engineer: �,- f / ✓�N-��
New Plans? Yes $275/Plan Check# (includes I"submission and one re-
review only)
Revised Plans?Yes $125/Plan Check# ll
Site Evaluation Forms Included? Yes No
Local Upgrade Form Included? Yes No__k
Telephone Fax#: 'Z4 Z J'
E-mail: �C , ✓�,�, ✓c'� ) �,�, 1„�. o
Homeowner
Name: v �/ .✓
OFFICE USE ONLY
When the CNnission is complete (including check):
➢ t Date stamp plans and letter
➢ k Complete and attach Receipt
➢ Copy File; Forward to Consultant
➢ Enter on Log Sheet and Database
O,`M011 TN,y V 6 L• 2
Town of North Andover
HEALTH DEPARTMENT
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CHECK#: DATE:
LOCATION: 6 69 s4,nn
H/O NAME: , ,-n,td/ -)
CONTRACTOR NAME/ e,5
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
tems:
❑ Septic-Soil Testing $
Septic-Design Approval •--- $,275-
Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
headI
h Agent Initials]
White-Applicant Yellow-Health Pink- Treasurer {