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No.
THE COMMONWEALTH OF MASSACHUSETTS
�I w�TH MASSACHUSETTS
FEE / s
&Nyptiration for Pieposal Sgedjextt Guetrurtion 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair'�j) an On-site Sewage Disposal System at:
Location Address, or Lot No. LO = j\) q
Dr�',/w� iv��P--2o
Owner's Name, Address and Tel. No.
toles 7 ��� w►, ,
IC:z.%�
Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
X06 — ]" 75 ,c' 7 0O
JRY-v\5S, W 6r�
A r>, L.L.,a C_
4 A i S
�r 1v -n- 0 _7-1-I, 0,1 A
L L 6 i 3
Type of Building:
Dwelling No. of Bedrooms 4 Garbage Grinder (Nz)
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow + + C) gallons per day. Calculated daily flow gallons.
Plan Date � 111 1 qS Number of sheets .Z a•'$�_ Revision Date
Title Sli7 ff PIA , riif,..� D0i!z Q6: It, LCT cis 4 tale "e,)d lbV-,
Description of Soil p ,
Nature of Repairs or Alterations (Answer when applicable) �+`1 F- 5 SVS-IC✓V1 Std r -u do-,\
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the vironmental Code and not to place the system in operation until a
Certificate of Compliance has been is e by is of Health.
Signed Date
Application Approved by01�' Date ��—I�/ 4 {
Application Disapproved for the following reasons
�
Permit No. C X S Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
a tov > MASSACHUSETTS
tEnttftrate jof TEantylinurr
THIS LY TO CERT[Fr, that the On-site Sewage Disposal System installed( ) or repaired/replaced ( ) on
by la AC, _EM_ for 251=126-7 A
at has been constrpk&d-,in
accordance with the provisions of 410 fie, �t-1 f ` ,.Lisl#odWAS�t� Construction Permit No. ! s -e Ga S' )' daltd
Use of this system is condi on compliance with the provisions set forth blw
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE Inspector
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