HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 160 CARLTON LANE 1/20/2019 NEB !
�G� TOWN OF NORTH ANDOVER
S6 '�Q� jz%9 Community&Economic Development
jN PNa° HEALTH DEPARTMENT
GOF N��pPR�M�N 120 Main Street
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HF��-� NORTHANDOVER,MASSACHUSETTS 01845
978.688.9540-Phone
978.688.9542-FAX
E-MAIL:healthdept@northandoverma.gov
WEBSITE:http://www.norffiandoverma.go
SEPTIC PLAN SUBMITTAL
FORM
Date of Submission:6/20/19
Site Location: 160 Carlton Lane, North Andover, MA
Engineer:Williams&S ara es, LLC
g P 9
New Plans? Yes X $275/Plan Check# (includes 1"submission and one re-
review only)
Revised Plans?Yes $125/Plan Check#
Site Evaluation Forms 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: Darren Winnie
OFFICE USE ONLY
When the wbtnission is complete(including check):
➢ Date stamp plans and letter
I
➢ Complete and attach Receipt I
➢ Copy File;Forward to Consultant
➢ Enter on Log Sheet and Database
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O` MORT.,4,
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Town of North Andover
HEALTH DEPARTMENT {
,S3ACMUSf'4 'I
CHECK#:3 a O 6 DATE: 0 o LA/9
LOCA
TION:
H/O NAME: . IAI)le i
,�, /115
CONTRACTOR NAME: ���� SyJ �
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 $
❑ TrasWSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
J�1 Septic-Design Approval $
I❑1 Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
Other:(Indicate) OGa $ o
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37 — nth Agent Initials
White-Applicant Yellow-Health Pink-Treasurer