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1443 Application & Permit 1999 lica FEE COMMONWEALTH OF MASSACIIUSETTS ON FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT truer( ) Repair(JJ Upgrade( ) Abandon( ) - Complete System U Individual Components e of Building 6,tJ6LE f I'�'nity Lot size ACRES -No.of Bedrooms er g g ° ( ) yi er-Type of Building No.of persons g Showers r/ C °-^ ( ) er Fixtures ign Flow vin.require. 1141 s: Date gpd Calculated design flow y q 6 Number of sheets 0— cription of Soil(s) —. Evaluator Form No. Name of Soil Evaluator . Lo Design flow proovviided4S�3p ' 0gpd Revision Date C' ' 2.41 �7lZ ' � Ir3'7 (�i7C� 98 Date of Evaluation SCRIPTION OF REPAIRS OR ALTERATIONS R&Pt.RCe- ,. ueSitNO/1Rf/ JLJ^r f7 U - DepoSAC. SySi1fv) e undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the protons of TITLE 5 and ther agrees to not to place the system in operafion until a Certificate of Compliance has been issued by the Board of Health. ned Date pecuen.s Owner's Namee. Q0 . S L.fflectoc sztion OP. •r%��frna ap/Parcel# Address /Lf Cues nomu DI# /Lf pRp Telephone# (�i3 _f�' r6 6 5O 7 istaller's Name —Mk/ 2 Designer's NatlnE �Fr6)MvO)/�.S 3 l.-& i��{ dress hit /P�s ) Address 96 .410 PAG_Lig l' I)V R elephone# 4 Telephone A )3 2 z 9 e of Building 6,tJ6LE f I'�'nity Lot size ACRES -No.of Bedrooms er g g ° ( ) yi er-Type of Building No.of persons g Showers r/ C °-^ ( ) er Fixtures ign Flow vin.require. 1141 s: Date gpd Calculated design flow y q 6 Number of sheets 0— cription of Soil(s) —. Evaluator Form No. Name of Soil Evaluator . Lo Design flow proovviided4S�3p ' 0gpd Revision Date C' ' 2.41 �7lZ ' � Ir3'7 (�i7C� 98 Date of Evaluation SCRIPTION OF REPAIRS OR ALTERATIONS R&Pt.RCe- ,. ueSitNO/1Rf/ JLJ^r f7 U - DepoSAC. SySi1fv) e undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the protons of TITLE 5 and ther agrees to not to place the system in operafion until a Certificate of Compliance has been issued by the Board of Health. ned Date pecuen.s FEE� 35s'`i COMMO nTII ®E MASSIIIIISETTS No. Board of Health,�� DL4.1? 1-11244^074 C 4TR OE COMPLIANCE CLRTIEI _t O Complete System „JuP�ded O.Abandoned( ) Component(s) Repaired WWW111°°° Work: ed�dual Disposal System; Constructed O. P Description of W ewage P The. d ���6[ dh hereby certify at the g 'IIt��'t"('� aI n lanx/u t nh plans re at ct ii Yf 31� and th PPT �)d 6 P r 9sio 1310 CMR 15 00 (Title 5) at e with d f APprOsed Design flow installed 31.7 � - / �/ 6a..been '6 , dated � �J�� Date: application o Wv'-, G(••�I <htspertor' will function as designed. Installer ie <INNI 5 guarantee that the system Designecf/4 r construed asagn%r g� aoesi designed.The is---s��ryryy�of this permit shah not be wnsm C®MM®NYC�LTR Oc N ASSfi4(,IILSEII S Board of Health, 'PI DISPOSAL SYSTEM CONSP ?CTION PERMIT U rade( ) Abandon( ) an individual sewage disf g as described in the ap; at hereby gr'•trted to; C rsn'act( ). `oe-p�ai[ �/ _a/1 3 � �� i�3�-�� dated 1�a� O . . nt local .tea ors m� Disposal System Construction be :Sr;pd,�' �y `oc �� completed within t ree years of the date of t/ pe m Form P .. Construction shall be comp ; V Board of Health Date - Y Form 1255 Fzv-5195 AM9uVIn CO.Boston MN