HomeMy WebLinkAboutHealth Permit # 4/1/1998 Town of North Andover, Massachusetts Form No.2
00RT#j BOARD OF HEALTH
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°•�°R °� ^'°' DESIGN APPROVAL FOR
9S$"CHUSEg SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant 0 BCC f '/—�"-V Test No.
: Site Location s 3 3R--1 4'f/uel- Z1
Reference Plans and Specs.
ENGINEER DESIGN DATE
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 4c'6 Site System Permit No.
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No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health,A eZ.4 ,m,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair O Upgrade O Abandon O- Complete System ❑Indvidual Components
Location g Owner's Name �� C
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Map/Parcel# Address �.
LoW t3% OW Telephone# Z,, E
Installer's Name Designer's Name ','
Address Address
Telephone# Telephone# 3 s 9 ��
Type of Building: Lot Size'(063S sq.ft.
Dwelling-No.of Bedrooms 4PISAE Garbage grinder(
Other-Type of Building No.of persons Showers( ), Cafeteria( )
Other Fixtures
Design Flow(miti r quired) gpd, Calculated design flow Design flow provided gpd
Plan:Date !L' r2 �� (Dumber of sheets Revision Date
Title
Description of Soil(s) c -u(
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluadon
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE
5 and further agrees to not to plac he,system in operation until a Certificate of Compliance has been issued by the Board of Health.
Date
v E
Inspections
DEP APPROVED FORM 5196
No. Fee
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
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