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Form No.3
Town of North Andover, Massachusetts
BOARD OF HEALTH
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'' ' DISPOSAL WORKS CONSTRUCTION PERMIT
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Applicant NAME ADDRESS TELEPHONE
Site Location
Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAIRMAN,BOARD OF HEALTH
i D.W.C. No.
Fee �
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DATE IVO i /9 y Sheet---,/ O
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
PERMIT # Cr= ,�
FEE %�=�� '� �-'� DATE RECEIVED,
APPLICANT l le__r/C.1,.1 AS SESSOR'S MAP
ADDRESS PARCEL #
LOT #
STREET
ENGINEER
ADDRESS
PLAN DATE rl /c� /�I REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED _
Town of North Andover, Massachusetts F°"""'°'z
(' NORIN BOARD OF HEALTH n
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DESIGN APPROVAL FOR
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ss^CN SE, SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
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T'• Applicant �IM Test No.
g; Site Location T� %ee
Reference Plans and Specs.
'. ENGINEER DESIGN DATE
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fit• Permission is ranted for an individual soil absorption sewage disposal system to be installed
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in accordance with regulations of Board of Health.
; • 'CHAIRMAN,BOARD OF HEALTH
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Fee Site System Permit No. "I'a
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FORM U LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Sr c � Phone � � �' ��y
LOCATION: Assessor ' s Map Number Parcel
Subdivision C(_1 � ��c�l Lot (s)
Street �� �l /��1t 'l le - St. Number
************************Official Use only******************* ****
RECD NDATIONS) OF TOWN AGENTS :
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Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
�-J t
iZ Date Approved �
Septic Inspector-Health Date Rejected
Comments
Public Works - se,:;er;water connections
- driveway permit
Fire Department
Received by Building Inspector Date
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