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-""-"