HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 288 STILES STREET 6/4/2020 RECEIVED TOWN OF NORTH ANDOVER
JUN 0 8 2020 Community & Economic Development
TOWN OF NORTH ANDOVER HEALTH DEPARTMENT
HEALTH DEPARTMENT 120 Main Street
NORTH ANDOVER,MASSACHUSETTS 01845
978.688.9540—Phone
978.688.9542—FAX
E-MAIL:healthdept@northandoverma.gov
WEBSITE:hqp://www.northandoverma.gov
SEPTIC PLAN SUBMITTAL
FORM
1
Date of Submission: f 2
a
Site Location: Z 5 9 S t-,
Engineer:
7 T
1
New Plans? Yes-C_$275/Plan Check# (includes 0 submission and one re-
review only)
Revised Plans?Yes $125/Plan Check#
Site Evaluation Forms Included? Yes No PreU�p�s� ��-a3M
Local Upgrade Form Included? Yes No--VIA
Telephone#: q-7 9 - g3-5--- 3,;? Fax#: �z rl
E-mail: i3 OS G-o o AA A t t-
. Con/1
Homeowner
Name: �' A-G E
r�
i
OFFICE USE ONLY
When the ission is complete (including check):
➢ ''k4 Date stamp plans and letter
➢ Complete and attach Receipt '
➢ Copy File;Forward to Consultant I
i
➢ Enter on Log Sheet and Database
. O
Town of North Andover
'�°•••:; ::�+ HEALTH DEPARTMENT
,SSAC HUSt�
CHECK#: 1d 6-� DATE: "� '8 -,?rD
LOCATION: 2,SR a-/
H/O NAME: ZqQe
CONTRACTOR NAME: ���90Oct
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type:_ $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
i
❑ Offal(Septic)Hauler $
I ❑ Recreational Camp $
r
❑ Sun tanning $
❑ Swimming Pool $
s
❑ Tobacco $
❑ TrasIVSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
XSeptic-Design Approval $ �>
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $ _
❑ Title 5 Report $
❑ Other:(Indicate) $
_ a
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer