HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 597 FOSTER STREET 11/16/2020 TOWN OF NORTH ANDOVER
Community& Economic Development
0�� HEALTH DEPARTMENT
VP
1 120 Main Street 60
�0 oFN��N NORTH ANDOVER,MASSACHUSETTS 01845 978.688.9540—Phone
00� R+�'.� 978.688.9542—FAX
N� E-MAIL:healthdept@northandoverma.gov
WEBSITE:hgip://www.northandoverma.gov
SEPTIC PLAN SUBMITTAL
FORM
Date of Submission: �� S Z A0
Site Location: 5 9 4- FA)rTfq- �Tky-c 7k �AOKT4- v K
Engineer: TWA-0
New Plans? Yes $275/Plan Check# (includes I"submission and one re-
review only) (�
Revised Plans?Yes $125/Plan Check# 6�
Site Evaluation Forms Included? Yes No
Local Upgrade Form Included? Yes No Y
Telephone#: (IN) JQCA Fax#: PIP
E-mail: 'Ccy1f'LW.f-mz:. oLi 1!!l 0 j t4-r- 1 .C w&
Homeowner
Name:
OFFICE USE ONLY
When tlWlu-MrNssion is complete(including check):
➢ Date stamp plans and letter
➢ Complete and attach Receipt
➢ Copy File;Forward to Consultant
➢ Enter on Log Sheet and Database
O, MOR7N'ly V '/
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Town of North Andover
HEALTH DEPARTMENT
�Ss�CMUSf�
CHECK#: DATE://, Xg.o?OA0
LOCATION:-5-9 / )iS/e. t- 54
H/O NAME: A!'o_�i/^ee-4
CONTRACTOR NAME:
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 Jr $
SEPTIC Systems:
❑ Septic-Soil Testing (e_V1 5 $
Septic-Design Approval $ f.
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
He Ith-Agent Initials
White-Applicant Yellow-Health ink-Treasurer