HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 997 DALE STREET 7/8/2019 i
TOWN OF NORTH ANDOVER
RECEIVE Community & Economic Development
HEALTH DEPARTMENT
120 Main Street
SAWN pF , 'IM041 R NORTH ANDOVER MASSACI iUSETTS 01845
N�1.SF1 978.688.9540—Phone
978.688.9542-FAX
E-MAIL:healthdept@northandoverma.gov
WEBSITE:h!W://www.northandoverma.gov
SEPTIC PLAN SUBMITTAL
FORM
Date of Submission:July s, 2019
Site Location:997 Dale Street
Engineer:Williams & Sparages LLC
New Plans? Yes X $275/Plan Check# 2109 (includes I"submission and one re-
review only)
Revised Plans?Yes $125/Plan Check#
Site Evaluation Farms Included? Yes X No
Local Upgrade Form Included? Yes X No
Telephone#: (978) 539-8088 Fax#: (978) 539-8200
E-mail: takerley@wsengineers.com
Homeowner
Name:Byron Leonhard
OFFICE USE ONLY
When the i ion 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
HEALTH DEPARTMENT !
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CHECK #: a/O 9 DATE:
LOCATION: 19
H/ONAME: /eO/)XcLr
CONTRACTOR NAME:
�.c>i//, �.L►� S d--' -)Acallia� of
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 $
X Septic-Design Approval $ S
f
❑ Septic Disposal Works Construction(DWC) $
I
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
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Agent Initials
White-Applicant Yellow-Health Pink- Treasurer