1268 Septic Application Septic System Permit Payment Receipt
Permit 142664 Z)Date: 4/21/04. Const Repair
Amount: 1.940 Cash Check#5 'q
Address: /01(17 - 6
owner: JFi .c4 ,• ei.�u
T, r
YlM111111■111OZrala 191N19•. aVE fuse •
DONALD G.WADE 5449
CONTRACTOR
165 RYAN R OAD & p
C 63 7168/2g
FLORENCE,MA 010623466 Date 11"-*
Pay Lo the i
$
I
Orderof _ .✓ L 14..._ .�....,
SS co
Dollars el
1. FLOkEN VINGS BANK
,/a/�w.AAm"o"MW nuramr.MA pion r�-f.
1i ror `1 0-- /1 P S pf 'f °
I: 2iLa ? LGaai: . 0L 25 '' LO ? L2.2ii' : 5449
No card aa,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
coy of ftiai2 Melia 7V^i
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
FFL'/ 2( OD P
5
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - =Complete System E Individual Components
/ 1 c & 13:.rfs /-, t Rd
cq/,?r°JCo
)-. ,..... t ,c,„.;,i-, r-- -
/2 C s- fL �: t- R d ip t i
�t;an
Map,Paral?
Address
rr�� / Lot p
ale na /c! 141 In - Cr ri Erb r s/
LlmhoncE
-amc
Insu Nam.
/ L { Rya ,t led Nrr-t,.d, /r.
^-
II'
De gnor.
/ _
Adatis
L/ / 1 _ 3-i-9- ///‘
E�Q®r�/
v
Telephone v
lei peon
Type of Building: S F 1) w e /// 3 l
Dwelling—No.of Bedrooms
Other—Type of Building
Other fixtures
No.of persons
Lot Size Sq.feet
Garbage Grinder ((Showers ( ), Cafeteria ( )
Design Flow(min. required) gpd Calculated design flo
Plan: Date Y/2//i G Number of sheets
Title Aba ., Dek∎ fx , ,T,nc- Se/Vie tn ,. k
Description of Soil(s)
N/ A
Soil Evaluator Form No. M /4 Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
n
w gpd Design flow provided gpd
Revision Date
AY ) 26k /30rts N4 Al Aac/ frr
JN AY µ Cr /, Ne
A'A Date of Evaluation NN//1
Pv / stptic Poly c. fvre 9.//a+. r Crvs/t IN re2
Nee '/ ' w6- kg) To /Ci $y C emet Lr NC
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TIRE S and furtheriagrees not p/lpce the s stem in operation until a Certificate of Compliance has been issued by the Board of Health.
.J(l 6 N.. ,Lt.I /L' Date 9' /0/ /C'
Signed
Inspections
FORM 1 - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96