377 Application & Permit 2007 COj1MONl\S'F tFIl1 OF j1ASSA III!SFITS
Board of Health, A)OttTHtMPro 3 MA.
APPLICATION FOR DISPOSAL SYSTEM CONISTI2I!CTION PERMIT
er mino Consmmt(l�ReoairO tips*rtde( 1 AbandonO - B'Complete System ❑Individual Components
Ir1: �
)P�des-‘033
pe of Building 0-Omse
yelling-Nu.of Bedrooms 4 BG0ROON4
her-Type of Building
her Fixtures
Lot Size 1.810 Acees
No of persons
arr grin )EINDE2
Gaba ey derr
Showers ( ).Cafeteria ( )
sign Flow (min-required) 440 gpd Calculated design fl ow 4(o6 Design flow prosided
In: Date Se-PC Zlo, ZOOS Num her of sheets Re.ision Date
.le ?1-4•11•3 OF ?ROPOSC SewACCe. DISPOSAL- SYSter
scription of Soil(s) SSE PEA-f3 f02 SOIL- w4s
it Evaluator Form No. Name of Soil F'aluaro .14cEeAIbDate of Evaluation 6/15/DS
466 gpd
iSCRIPTION OF REPAIRS OR ALTERATIONS
le undersigned agrees to' tall the above described Individual Sewage Disposal System in accordance with
rther ageee s to not to pl e the system in operation until a Certificate of Compliance has been issued b
owe( Yh( e41a .tr/41./ Dale j- j- CC.
spec nuns
vocation 14.4.61L-VEST 'v 1..: a-
•
Owner's Name NE115__ SE M O U' ..o
dap/Parcel#
Addres36141 LAN/Esfi@'L--12D. Jo(tj114 - e
-Ielephnne# (4 11) X65 — 8306
not ?kern._ Z_
nsraller's Name Mnrla. Ex Co rn/)
KK�i'
Designer's Name f.�.�trAyE S Jo4eN/S iIJ�, .
h^'
address/OS Ply,, tot ak IMWi
an
AddressCOL�E ti A UJAV 4 CLA J S(P-ECT ?.0.ea(1
relephonell(111),1 OS - �1 ,_�
Telephone#L413)511-3(OO 500114• 1-kerOn)
pe of Building 0-Omse
yelling-Nu.of Bedrooms 4 BG0ROON4
her-Type of Building
her Fixtures
Lot Size 1.810 Acees
No of persons
arr grin )EINDE2
Gaba ey derr
Showers ( ).Cafeteria ( )
sign Flow (min-required) 440 gpd Calculated design fl ow 4(o6 Design flow prosided
In: Date Se-PC Zlo, ZOOS Num her of sheets Re.ision Date
.le ?1-4•11•3 OF ?ROPOSC SewACCe. DISPOSAL- SYSter
scription of Soil(s) SSE PEA-f3 f02 SOIL- w4s
it Evaluator Form No. Name of Soil F'aluaro .14cEeAIbDate of Evaluation 6/15/DS
466 gpd
iSCRIPTION OF REPAIRS OR ALTERATIONS
le undersigned agrees to' tall the above described Individual Sewage Disposal System in accordance with
rther ageee s to not to pl e the system in operation until a Certificate of Compliance has been issued b
owe( Yh( e41a .tr/41./ Dale j- j- CC.
spec nuns
ti •.L —1.? reE/
Board of Health, /t%1r ;tie;,a) J NFL S
CERTIFICATE OF COMPLIANCE
scription of Work: ]Individual Component(s) ❑Complete System
c undersigned hereby certify that the Sewage DJposal System; Construrted (by;Repaired ( 1,Upgraded (),Abandoned ( )
/ '/r:u� ) ,t=79'/ <j a/ p � .r� � ' — /9,7k,',1,r-ah; -77,L1
7 3-(i � fr....:1?i�rtE'� o_+t. _ /9, 7� //i• y's r ,;Y
/ f+
been installed In atcordancc with the p t asio s of 3,1,0 CMR 1- 00 (1'tl o) and the approved design plans/as-built plans relating to
,lication NB. 27 '1 — 'dated Ai( tr Approved Design Flow 114 (gpd)
alter r�.i1 IVT 1 _
:J' tie° nate
signer: / rm: ; r
COMMONWEALTH OF MASSACHUSETTS
e issuance of this permit shall not be construed as a guarantee that the system will function as designed
6 -/2
COMMONWEALTH LTH OT MASSACHUSETTS
Board of health, )/j0" Gc(C✓� %/MA.
DISPOSAL SYSTEM !C NSTRULTTION PERMIT
granted to; Construct(vVeRepair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
described in the application for
sposal System Construction Permit?(M.., v(Gy� 7 dated ( / IJR;C
ovided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
1 126 see 5 tns A M SuIke Ca Boston.MA Date �Boand of Health
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