305 Application & Permit & Plans 2005 lion for a P
COMMONWEALTH OF MASSACHUSETTS
Board of Health, {�Yr1TLl/�wnf_gpi. MYA.
PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
rmit to Construct(/Repai*Ulpgradel ) Abandon( - ❑Complete System l4l2dividual Components
,ion 305 6./ ST-1-1 JA�� RD
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64-4,1')
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Owner's Name Th..kas D1tMl0$
JD
,Parcel#
Address —1-0J1)
ST — «I- An A-
Telephone# (4g) 52:1 •""52.3a t
Iler's Name �L E Grp rTheiN
tsk I )$signer
Y�. "s7T�
s Name .6 dad,s as
/ddress J
ess /90 am.- 61 &A
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Telephone# (4—v33 sZi — S29
Building eli6L.€ ..may i}o Ake
g-No.of Bedrooms 4-
Lot Size
sq.f
Type of Building No.of persons s. Showers 'Y'
ixtumes
Flow (min. required) s------ gpd Calculated design flow Design flow provided gpd
are �1O1 'ZOO Number of sheets 1 Recision DateM)/'+
S t.c `ANK- QUA ti
lion of Soil(s)
Luxor Form No.
Name of Soil Evaluator Date of Evaluation
IPTION OF REPAIRS OR ALTERATIONS FZ.kcial FAL Li Al 6 SR45rLC t cat?'
11-7A-1 toRu) LSn Secn< W trmj Mut.6
LchAtiNtaffACT
lersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
o not to�plac ��e system in operation until a Cate of Compliance has been issued by the Board of Health.
ei-er/�// %" Date
ons
COMMONWEALTH LTH 0O ALASSACILUSETIS
Board of Health, , / 117; MA.
14- TITICATE It C 6MPLIANITh
ption of Work: 'dual Component(s) -Complete System 'Nei e r j
idersigned hereby certify that the Sewage Dismoal System; Constructed ( ),Repaired l ).Upg aded ( ),Abandoned ( )
r �---*- ty' .T. C. at C,/,� ) t N() *ya�a ) / A 4327 52
4, �-`T nit 4 .. .
en installed in accordance with the provisions id 310 CMR 13.00 (Title 5) all q d approved design plan/ sbuilt plans relating to
i Nu Z�5 ZS date M /b/ Qr. Approved Design Flow r/4 (gpd)
e. i L t( lilt (yj G /—✓v^
ter: -I;/y, , A-G/4`5N%S Inspector: %//Jn970rik CJ� Date: t . !ds-
sus/ice of this permit shall not be construed as a guarantee that the system will function as designed.
r'S—fit,
he 71741 ofLy
COMMON WL\LT1 01: 141SS, a,,IILJSLITS
Boma of Health, / / r' _ Ay
EP E SA__
ett
ebei it- CM
DISPOSAL SYSTEM I O1N1STRUCT1ON PERMIT
P/ . <i ' /%`T/ 7,dit
ission is hereby grantgd to; Construct( ) �7 Repair ty) Upgrad/, AbandcXS( ) an individual sewage posal system
2/ 6S— iu7-1 11,fi ,- , t& 1 '- I ‘6)�e2,,,9 1.7 �-61,07n as described in the application for
mat System Construction Perhit No.(*6(2Z C.dated O. Z-Ovar
ded: Construction shall be completed within three years of the date of tl ' permit. All local conditions must be met.
5 Re 5,96 AM.SUIkin Co.Boson_MA Dar Board of H calf li
'Mae"
c o nuw%% iltarRigen
on t Markers,Length=0 feet
ampion Raod- 04?18'23.4"N, 0n°41'00.5"W
: EASTHAMPTON
5/9/105
: 1 inch equals 2000 feet
Location: 042° 18'03.6" N 072°40'36.0" W
Caption: Septic tank replacement
305 Westhampton Rd. (Rt.66)
Northampton, MA
Copyright(C)1997,Maptech,Inc.
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