HomeMy WebLinkAboutMiscellaneous - 26 STANTON WAY 1/19/2016 TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; SUITE 2035
NORTH ANDOVER,MASSACHUSETTS 01845
978,688,9540-Phone
Susan Y.Sawyer,REHS/RS 978.688.8476-FAX
Public Health Director E-MAIL: healthdeDt((i),townofnorthandovei-.com
WEBSITE: httL)://www.townofiioi•thaii(lover.coi-n
SEPTIC PLAN SUBMITTAL FORM
Date of Submission:-
Site Location: Lot 16-8 Saracusa Way
Engineer:Christiansen & Sergi, Inc.
New Plans? YesXX $225/Plan Check# 6 / V02 (includes I" submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes No Xx
Local Upgrade Form Included? Yes Noxx
Telephone#:978-373-0310 Fax#:978-372-3960
E-mail:-phil@csi-engr.com
Homeowner
Name:G.M.Z. Realty Trust
Applicant: Green & Company, 11 Lafayette Rd, No Hampton, NH 03862 800-429-8615
OFFICE USE ONLY
When the submission is complete(including check):
➢ Date stamp plans and letter
Complete and attach Receipt ......
RECEIVED
➢ Copy File; Forward to Consultant
➢ Enter on Log Sheet and Database �IAY 0 3 2013
TOWN OF NOR 111/kND(WER
tAr
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No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
OF N66 7 H —hN )-1(M1
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct (,>4 Repair Upgrade Abandon ["Complete System ❑Individual Components
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won Own is Na N
11 L(A-6etk, �,l ov �/o/I 0 il (os
Map/ # Address
06) 2
Lot It Telephone A
Installer's Name DA N
Address ct 3 A ress
. 1,3 0,31 /'0
Telephone# Telephones#
Type of Building: arrir f—,a Lot Size 4�,, ''I ' 11?61 Sq.feet
Dwelling—No.of BedroAms Garbage Grinder 4 L)
Other—Type of Building No.of persons Showers Cafeteria
Other fixtures
re
Design Flow(min, d) gpd Calculated design flow—gpd Design flow provided gpd
,-7uire
Plan: Date Number of sheets Revision Date
Title Sqih�,., to-f tl, -fj "CU.SA wa,f"i ioA
V \j
Description of Soil(s) Xb"
Soil Evaluator Form No.414 Name of Soil Evaluator &(jW Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersign afire s t®- st the above described Individual Sewage Disposal System in accordance with the provisions of
fur, P
TITLE 5 and fort undersign
rr r" the system in operation until a Certificate of Compliance has been sued i"111".11,11, "If
Signed Date MAY 03 201,3
Inspectio is
'rom or,� IIM'iIII N',F DOVVZ
_r7"I"Z
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96