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Form No.3
Town of North Andover, Massachusetts
BOARD OF HEALTH
IAORTH
L
T
DISPOSAL WORKS CONSTRUCTION PERMIT
- SS•1CHU56
Applicant �LE NE
NAME DDRESS/�I"
Site Location i pt 1'u,
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
Fee 95 D.W.C. No. r' 33'"
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
60 wx
DATE:- CUR-RE'NT INSTALLER'S LICENSE# ~
LOCATION: Z0_/ 1A 1,4)k)q A" AA,, t'sUe,
V
LICENSED INSTALLER:
SIGNATURE: TEA LEPHONE# 91 f I
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes- No
Foundation As-built'? Yes- No
Floor plans on file? Y s_ No
Approval Date: