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Town of North Andover, Massachusetts Form N®.a
Q 00R*w BOARD OF HEALTH
O't,Leo a,O (` '
19
al' ea' i
DESIGN APPROVAL FOR
: �SSACHUSet4� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Test No—ks y
Site Location All � ✓R �
Reference Plans and Specs. _4
ENGINEER DE81G D E
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
Fee f Cl
Site System Permit No.� r w
'No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
11 k1AJ
APPLICATION I FOR ISIS SAL SYSTEM CONST UC TI i PERMIT
Application fora Permit to C:onstrnct (r"l 1� cpadr ( ) Upt;rrrdc ( ) Ataandoti ( ) [,]'f omplete System ❑hidividtral C'onapoijents
,w1eru7°. �m � tti�r�i� k�?M'rre��..6d�„@, fiTdtr.,� 8a
N y� �°t� � Owners b�
� r
MaplParcul At Address
i'mY�� rt C b�a.l
-
Lot k - - relephunc A
i
l)esi h nci s(Name
[nsuillcr's Name ,p r
Address Addr,sr
Tcicphinre P Telephone 4
Type of Building: _-- Lot Size___) t' M- . Sy,feet.
Dwelling—No,of Bedrooms -_ Garbage Grinder ( )
Other—Type of Building_ No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(ntin.required) gpd Calculated design flow �j1, �1 gpd Design flow provided !&A2 gpd
jflan Date Numb r of sheets R”"eva�tsi
on Date
Irtle L
—
Description
iu for Forms No Name of ����� # �A �(
r �°
of Soil Evaluator 5 w s�&"dot 0i.3 Date of Evaluation A
(
DESCRIPTION OF REPATRS OR ALTERATIONS n
"ro t rt re es�1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fur reesFnot t place theks stem o erYiora antia Certaf tee, sgrnl���ce�has been issued bYf �rJ Health.
F g y p p p y we Boar o
Signed ,�F� ;� rMia <<'i,,,, , _ y� °
± — —
IYYSIYections ' ,
FORM 1 - APPLICATION FOR DSCP OEP APPROVED FORM 6/96
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned
by:
at _has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application.No. .— dated Approved Design Flow (gpd)
Installer
Designer; Inspector Date _
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE ®EP APPROVED FORM 6/96