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11 Application & Permit 2003 FE,5� COMMONWEALTH OF MASSACHUSETTS Board of Health, Norfhamp%Orl MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT .pplication for a Permit to Construct( ) Repair( ) UpgradeQO Abandon( ) - O Complete System fki Individual Components Location I1 J ht}+I Cr 5+reed FFiore.nct Owner's Name Br ma rd T. OIL nnor Tr Map/Parcel# 143 / 094 Address I I whiff:ex 3+reef Lot# 15 Telephnne# (LI I3) 181- 5311 Installer's Name Wh kit Cxcatra y to!� Designer's N:nne eril-q Surpvey3 Tc. Address 4!o fro pie_ 5}rce} S�uN-.amNion ye Address L ork Si Ccilet 19heuay ^ S Po. BoxI Telephmne# C413) 527-232/ Telephone 13 -27- te 5aufhamp#04-1 epe of Building NOOje wetting-No.of Bedrooms k_x161,,1±1 3 b'eirn0Y1 Lot Size £13. Z940 sq.ft. geriuvIII Garbagnder ) other-Type of Building No.of persons Showers( ),Cafeteria() Pt lit r Fixtures esign Flow (min.required) 3 30 gpd Calculated design flow 3 S 7 Design flow provided 3.3 7 gpd Ian: Date C Gfnbe r 2003 Number of sheets I Revision Date itle Plan at Proposed 5e via�e DisaoSal Sy.41- n-- Upgrade -- eynard %C'CaororR ascription of Soil(s) 5e L Plc, - -or Sn. i Logo ail Evaluator Form No. Name of Soil Evaluator ESCRIPTION OF REPAIRS ORALTERATIONS R A BaLk±M Date of Evaluation July 7, 2003 Tn sfalledtn Of a. Jr000sed 12'x 38' rbcinn ee - ! — — IbFh l c It ASH OF alt N he undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the pro of 5 . It nther a to not to place the in operation until a Certificate of Compliance has been issued by the Board O tt g V � . 1Ok2A1O3 Aft gned e Date vr..)tt w, ,w� p Cam-aji ispections _fl it COMMONIT( 1LTII OF MASSACr]I[!SFTTS Board of Health, CERTIFICATE OF COMPLIANCE Description of Work: 'U Individual Component(s) D Complete System 'Me undersigned hereby certify that the Sewage Disposal System: Constn:ried ( I.Repaired ( Upgraded O .afraid oned ( ) by: FFF at has been installed in accordance-with the provisions of 310 CMR15.00_(Tidc 5 U and be app l rd d,-dgn plans/yypnllt plans relating to application No . dated . Approved Design Flow (gpo) Installer Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that die system will function as designed. re COMMON-WEALTH OF MASSACITL'SLTTS DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(X Upgrade( ) Abandon( ) an individual sewage disposal system at - - - as described in the application for Disposal System Construction Permit No. �� - ' � .dated � A. r Provided: Construction shall be completed within three years of the date of this ripen it. MI Ioca tohdiuons must be met_ EDIT.1255 Rev.5'96 A M.swno co.AMMO MA Date ;i ' 2 Board of Health Y ` ._ //`s- C/ /''4-""-"