155 Application & Permit 2004 FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health,_harD:lea MA.
ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
of Building
ing-No.of Bedrooms
r-Type of Building
r Fixtures
n Flow (min.required) 3..2/�
Date tti-7.G-6 3
S I IJl&( /Am I Ly 1-1-cmA
Lot Size go cog— sq.ft.
Oaf Los,gi baler ( )
No.of persons Showers Kr_c° _1e- )
M A
gpd Calculated design flow
Number of she
Lillian of Soil(s) pi An) t Coil- 50{3(tt AC\
.valuator Form No. Nance of Soil Evaluamti Date of Evaluation
IRIPTION OF REPAIRS ORALTERATIONS spA42 frrUD t4)CkA i kicASTtJC
tQ)fs T DcSo&nl Syssa
33)
Design flow provide 6741'.i b gpd
Revision Date
-'i4
undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
Ter agrees to not to place the,system iu operation until a Cer9 Eate of Compfiance has been issued by the Board of Health.
ed -✓40. o , ? ert, /Date h9 /d I_I{,
eedons
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owner's Same n IAAallAy 5 tM2A S OCC
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p/Parcel#
Address q 1 LA,R�5-029.� R �L R-D
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Telephone# (4g) - os9 9
alley's Name
De signer's Nam e-11-'4..4)0
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I( AAn��cI�- MS F5
Tress
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ephone#
Telephone# (4■31
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of Building
ing-No.of Bedrooms
r-Type of Building
r Fixtures
n Flow (min.required) 3..2/�
Date tti-7.G-6 3
S I IJl&( /Am I Ly 1-1-cmA
Lot Size go cog— sq.ft.
Oaf Los,gi baler ( )
No.of persons Showers Kr_c° _1e- )
M A
gpd Calculated design flow
Number of she
Lillian of Soil(s) pi An) t Coil- 50{3(tt AC\
.valuator Form No. Nance of Soil Evaluamti Date of Evaluation
IRIPTION OF REPAIRS ORALTERATIONS spA42 frrUD t4)CkA i kicASTtJC
tQ)fs T DcSo&nl Syssa
33)
Design flow provide 6741'.i b gpd
Revision Date
-'i4
undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
Ter agrees to not to place the,system iu operation until a Cer9 Eate of Compfiance has been issued by the Board of Health.
ed -✓40. o , ? ert, /Date h9 /d I_I{,
eedons
c',2(l 1/-r3
COMI1ONL:ILTII ()I b\SSACI IUSLTTS
Boanl offlea//h, .MA.
Willi;IC NH OE COMPLIANCE
iption of Work: U Individual Component(s) J Comple}_g System
to dersigued hereby certify that the Sewage Disposal Srotem; Constructed O.Repaired ( Upgraded ( ).Abandoned ( )
FFF
ecn installed in acc ordance with the pi otisions orv,10 CMR 15.00 (I lily B) tmd the approved design plans/a,-built plans relating to
cation No. . dated Approved Design Flow (gpd)
ci
t lu.pectur Date:
ssuance of this permit shall not be construed as a guarantee that the system will function as designed.
3
CON MONWEALTLI OT M1ASS:I IIIISEITS
Board of Health, N7 (77:1/7%jt/7% .1Lt.
DISPOSAL SYSTDI CONSIPLCTION PERMIT
1 iSS9.1P,is heypbv granyrd to; Constytct( _ t( ) a pgta ( ) .Abandon( ) an indiidtml sewage disposal system
q
,/ AU47 7 J�if / C " i ) if'l/�¢ //i.17((JA o»)L 4/as described in the application for
osal System Construction Pe mit No.,,t66 / C 3 • dated (73i) /fy
FEE/ /b" 'PI
A y ;
ided: Construction shall be completed within three years of the date
55 Rev 5196 wm swasa.assmn.MA Date 4)/0 �%Board of Health
}iy permit All local conditions m List be met.