174 Application & Permit 2001 FEE
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COMN1ONWL \LTII {)F M lSSACIIUSUTS
Bo rd a/Heals. Nor!ha wl pt OVl , pan.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
anon 5. nno,
Map
Parcel
ee
Owner's Name Andrew Church
5 .n. Street No ham ion
413) 58 , -ZI8
Sure
Install
uldresS
Telephone
Address I74
Telephone#
Designer's Name Rah fa
Address G
Tclephonei
'cpe of Ruilding
hvelling-No-of Bedrooms
hher-Type of Building
E. P O
Q ,5n ha
Lot Size
97.623 AcR't5
&bTe grinner
_ ar agegrnt r )
No.of persons_Showers ( ),Cafeteria( )
)thee Fixtures
)esigu Flow (min.required)
'Ian: Date Tune t9 �1
rae . • n se
Description of Soil(s)
Soil Evaluator Form No.
gr
Calculated design Bow Cali tilated design 444
Number of sheets Revision Dale
Ds oXi S For ADdre Ckure
Design flow provided 444 gpd
CSI15/`1n
Name of Soil Evaluator KCLI Date of Evaluation MDT�`
DESCRIPTION OF REPAIRS OR AI TERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree to no to place �- tem% operation until a Certificate of C liaQ�i as been issued by the Board of Health.
Dam /
Signed SW
Inspceti(uS
FRE
TOI\IN'IONWLA]TI1 or 'LASS/VMS-MS
_t�
TLRN:'CATE_ or IO1IPLL\NL
eseription of Work: J Ind vidual Component(s) J Complete System
it
undersigned hereby certify tl a t the Sewage Disposal(System: C nsvocted ( ).Repaired ( ). Upgraded ( Aba tdoned ( )
as(then iththIls d ' i co dance with the pro +of 3I()CAW 15.00 (Title of and th( apposed des'gnr plans h huilt plans relating to
1- don No. . dated - :Apprtned Design flow (gpd)
pp it.t —
ist uer Date:_ ht,pector:
'he issuance of this permit shall not be construed as a guarantee that the system will function as designed.
i3O>I>ION v 11tvLTII Of MASS1I I1USLTTS
Board oplealth, A%:/2 ' t°/1.4/1/ 4 . ALA
DISPOSAL SYSI I i1ONSTx21t[,IION P-EPIIIIT
Permission is hereby panted to; Con si iicr Repair( ) Upgrade( ) Abandon( )an individual sewage disposal s;stem
�CPa r/ / 7 i/ �,-4 �. ) Si"-„°r.ns Etas described in the application for
at �o� �C ']
Disposal System Consnuction Permit N . C/'fL-
ed i /';/r
Provided: Court non shall be completed within three years of the date of this p rn t All Its al co`nnditiohs must be met.
o _ (
t rz Rey sss n s Co at,ior ,IL Date �a S%o�� Bard of I lealdt /- -�e^ PC—LI
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