HomeMy WebLinkAboutApp-Permit-Compliancer No. !(0 -736 FEE So' r
THE COMMONWE LTH OF MASSACHUSETTS
MASSACHUSETTS
cXyyfirativn for Pisposal *Votem (fous#rurtion Permit
Annlication is hereby made for a Permit to Construct ( ) or Repair 06 an On-site Sewage Disposal System at:
Location Address or Lot No. .hp � '1
Own is Name, cess aid Tel. No.
l 70
W R Oman -4 L07''e �'
S' 2ZJZi C -U-)
Installer's Name, Address, and Tel.No. q
w6wifLlELIQ
Designer's N�aamQe.AAddress and Tel. No.
ee(?
4E ♦ .4 A ,0 (C
Type of Building:
Dwelling No. of Bedrooms
Garbage Grinder ( )
Other Type of Building
No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow 33-3
gallons per day. Calculated daily flow 3 0
a
Plan Date ? Z7 Llo
ry ^gallons.
Number of sheets Revision Date a- -"�' 6
Title
Description of Soil
Nature of Repairs or Alterations (Answ hen applicable)
Date last inspected:
Agreement:
The undersigned agrees t
sure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the pr i ons of T' e 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance h s iss
d this Bo deo H th.
Signed
Date S�
T
Application Approved by
Date
Application Disapproved fo the folio mg reasons
Permit No. 5a�
Date Issued `r b
^4&4'�
THE
COMMONWEALTH OF MASSACHUSETTS
f2 ; �( Q)r / , MASSACHUSETTS
01
CJPrtifirate of (gontylianre
THIS IS T CERT- that
n -site Sewage Disposal System install( ) or repat a /replaced K on
-�' ^--I` by U
CJS /� for ^-JCSH,^1 %
at /It
h s ee cp ructed in
(p
accordance th l� rfy��visions of Title
5 and the for Disposal System Construction Permit No. dated
�J/O
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be
Certificate expires on
DATE /-)- .
as a guarantee that the system will function as designed. This
Inspector