320 Application & Permit 2005 a20%
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CC)' grnnv,'F A'LTiI OF MASSACERISEITS Gee*- 2.6-3
Board of Heal!lt g10Ra'kiAMP}l1 a . MA. pa ovpiateriv
FOR DISPOSAL SYSTEM CDNST,�QTION PERMIT
—54
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EOtirpof HEALTH � E r di "
il'Comolet S rem s7ln_ vid al Compm ts,y� 17 L/_
E Building
Noose.
ng-No.of Bedrooms 5 412.
-Type of Building No.of persons
Fixtures
I Flow (min. required) 495 gpd Calculated design flow 504 Design flow provided SO4- gpd
Date Mdsra 151 ZOOS- Number of sheets I Revision Date b 41ZC.0 25, 23OS
PLA,3 of pPo set, Seb. A4ett5Past5- tistetA UP4t C
puon of Soil(s) SCte PLf}wifag- SD it— W4S
valuator Form No. Name of Soil Bat
Lot Sire 11.244 sq.ft.
(,ar ag6 'e grin el ( )
Showers( ),Cafeteria ( )
°R -Q- NcEtLMJ Date of Evaluation
223-or
RIPTION OF REPAIRS ORALTERATIONS INSvtaflf10 J of A 7-41,4 3C1 Le c$ FIct-0,)\>1Stle-1 •Uflbt)
iced 4M.. Fume aerrca _) Soo 4A.L.6entc-'CMT1t< tIHPErd US (3RSYtK0 U1
a
ndersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisi
er a not to Rlace th system in operation until a Certificate of Compliance has been is ued by the Board
YC/]CV�wsw— Date J-Le'OS
Mum
of TITLE 5 and
th
Lion 31_o h{L.VCSsec 523) tr--)021}}45r1Pdvr')
Owner's Nine eSfltt of(<gTNWila U4JBt-
/Parcel# ZS /9
R
Address 1131PEsTfA4+5ubleunte ce, ,HA
P I
Telephone# A\3- s84' 65s-8
tiler's Name £j ( 1
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Designer'Name ViegAtA4e SJRJOfS 11wIG
„2,e0 /
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.address frlrf�E l#l4HWAy 4 C4A[.�3'�12G'er BO-Foci
ne# /
phone# v --
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' Telephoireu 413-5X1-3600 sounw-taltwl
E Building
Noose.
ng-No.of Bedrooms 5 412.
-Type of Building No.of persons
Fixtures
I Flow (min. required) 495 gpd Calculated design flow 504 Design flow provided SO4- gpd
Date Mdsra 151 ZOOS- Number of sheets I Revision Date b 41ZC.0 25, 23OS
PLA,3 of pPo set, Seb. A4ett5Past5- tistetA UP4t C
puon of Soil(s) SCte PLf}wifag- SD it— W4S
valuator Form No. Name of Soil Bat
Lot Sire 11.244 sq.ft.
(,ar ag6 'e grin el ( )
Showers( ),Cafeteria ( )
°R -Q- NcEtLMJ Date of Evaluation
223-or
RIPTION OF REPAIRS ORALTERATIONS INSvtaflf10 J of A 7-41,4 3C1 Le c$ FIct-0,)\>1Stle-1 •Uflbt)
iced 4M.. Fume aerrca _) Soo 4A.L.6entc-'CMT1t< tIHPErd US (3RSYtK0 U1
a
ndersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisi
er a not to Rlace th system in operation until a Certificate of Compliance has been is ued by the Board
YC/]CV�wsw— Date J-Le'OS
Mum
of TITLE 5 and
th
COMMONWEALTH Of MASSACHUSETTS
Board ofHenkly /9%/55 19y 777 MA.
CERTIVICATE Of COMPLIANCE
ion of Work: O Individual Component(s) J Complete System
lersigned hereby : rtify that the Sewage Disposal System; Constructed () Repaired ( ).Upgraded ('f Abandoned O,.
+ ae iee C/ I < /
«-/#vt i✓c, 7;'gym ' A) ,. 1
j L," Li-Tr A-I-D
installed m accordance with the provisions o)10( SIR 1500 (Title 5) andthe approved design plans/as built plans relating to
ion No. , -v" •) datecy w..H 15. ?S . Approved Design Flow 'se- f (gpd)
✓'r-it;'< tai/+- . LE-4
sS :,
FEE
a ec.
Inspector: .'T✓y e u1hCi Dat
lance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
✓ pt yn i c""St u-71 gy
p Board of Health / .e (17e2, 7J//i AM.
E ti
�N ` NSPOS1b SYSTE CONSTRUCTION P Jth HT
/oMP '_S/0JUr
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soon a Belay granted to; Construct( ) Repaint/7) Upgrade hA Abandon( ) an a dnidua l sewa
disposal system X/� �, c
✓ %�0 7 L Tf` / l_"y�as dexnbed in t.- eL ppIGu!o<n V for r
i
sal System Construction Permit N�Nr )- ,rj. ,dated t l)
u 5
.
led: Construction shall be completed wit n three years of the date of this permit. All local conditions must be met
ae, 5 9 au scis.,co.eoctm.con Date/Sr/MO Board of Health eY
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