HomeMy WebLinkAboutApp-Permit-ComplianceNo. 9 `f {¢ FEE .5d - 67
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
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Application is hereby made for a Permit to Construct ( ) or Repair ( ) an On-site Sewage Disposal System at:
Location Address or Lot No. AT 71f Z07_#__ Owner's Name, Address and Tel. No.
7 S7"AR d3UaK 1.N. ���emo �%�/� y waa I
Installer's Name, Address, and Tel.No. Designer's Name, APAK®nCWM- TANTS
K �_I 91445 Perc. Tests & Plans
Box 615 E. Dennis
CAPE COD 02641
Type of Building:
Dwelling No. of Bedrooms 4 Garbage Grinder (N)
Other Type of Building -DwEllh u No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow s' 3 , Z gallons per day. Calculated daily flow 44•o gallons.
Plan Date 9l 30 �9S Number of sheets Revision Date O
Title
Description of Soil &E,j►)����/e SArcU�
Nature of
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 Environmental Code and not to place the system in operation until a
Certificate of Compliance has n 'ssued by this Board o ealth. >> g
Signed ` Date,--1,0/S/`
ate/® S3
Application Approved by Date
Application Disapproved for he following reasons
Permit No. g� 71/Q
Date Issued �U _.
THE COMMON tE-A TX MASSACHUSETTS
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1M.: ASSACHUSETTS
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THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed ( ) or repaired/replaced ,1') on
by P4-& for �if7l�l repaired/
at 7 /L z"m/gr— has been constructed in
accordance witp the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate ex ires on i�l n
DATE d' Inspector / !�
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