HomeMy WebLinkAboutHealth Permit # 5/5/1998 Town of North Andover, Massachusetts Form No. 3
` e AORTH BOARD OF HEALTH
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�► 'o °� DISPOSAL WORKS CONSTRUCTION PERMIT
,SSACHUSES
Applicant
NAME ADDRESS TELEPHONE
Site Location �/� t�(,���cSI�YJ Jh
Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. AW 2
CHAIRMAN, BOARD OF HEALTH
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Fee No.
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (�) repaired;
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located at eZ
was installed in conformance with the.North Andover Board of Health approved plan, System
Design PC=t.T9/2 , dated Y"Jd' G/� with an approved design flow of.�
Gallons per day. The materials used were in conformance with those specified on the approved
plan; the system was installed imaccordance with the provisions of 310 C MR 15.000, Title 5 and
local regulations, and the final grading-agrees substantially with the approved plan. All work is
accurately represented on the As-built which has been submitted to the Board of Health.
Installer: Lic. Date:
Design Engineer: Date:
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: . ° ley- CURRE NT INSTALLER'S LICENSE#
LOCATION; ' , �:� as,.,� S4, �>( > � t : a4b,
LICENSED INSTALL
SIGNATURE: T PHONE#
CHECK ONE:
_ REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes V/ No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval ? , Date:
a.