HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 125 BOSTON STREET 11/23/2021 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:hqp://www.northandovenna.gov
SEPTIC PLAN SUBMITTAL
FORM RECEIVED
JUL 2 8 2020
Date of Submission: `7�/0 D 1•-O
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Site Location: rhos-r&!,, S t
Engineer: �aM EC, 04 OVLA-_�
New Plans? Yes $275/Plan Check # (includes I't submission and one re-
review only)
Revised Plans?Yes $125/Plan Check#/
Site Evaluation Forms Included? Yes V No
Local Upgrade Form Included? Yes No
Telephone#:D 4—to qtg a 1p Fax #:
E-mail: 1-ri t'_-a Ne LJ oo SS i'mow �--
Homeowner ��Zj
Name:
OFFICE USE ONLY
When the s mr 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
Cf`NORTH,y
Town of North Andover
HEALTH DEPARTMENT
SA US
CHECK#: DATE: ,
LOCATION: An570n 25
H/O NAME: 4 nrJe LlS
CONTRACTOR NAME: 7�t-/hESo!'i/�
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 $
] Septic-Design Approval
❑ Septic Disposal Works Construction(DWG) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer