HomeMy WebLinkAboutApp-Permit-Compliance10�4.. ,.
No. � 7� FEE
THE COMM ALTH OF MASSACHUSETTS
/'
('s p MASSACHUSETTS
055 - �Jo cXjjyfiirativn for Pisposal �*VoteC� its#r�xr#t��t 1jerntit
cC, Q Application is hereby made for a Permit to Construct ( ) or Repair ( an On-site Sewage Disposal System at:
CCC. l9
Location Address or Lot
Owner's Name, Address and Tel. No.
r
Instal er'sAddr s, and Tel.No.
Designer's Name, Address and o.
2--3 —V� a-, x -
4001*01�
Type of Building:
Dwelling
Other
Design Flow
Plan Date
Title
Description of Soil
No. of Bedrooms Garbage Grinder ( }.tc�
Type of Building No. per Persons - Showers( )
Other Fixtures
gallons per day. Calculated daily flow
Number of sheets
Nature of Repairs or Alterations (Answer when applicable) _
Date last inspected:
Revision Date
to
Cafeteria ( )
gallons.
Agreement: 1 2p1pb3tINp5
The undersigned agrees to ensure the construction and maintenance of the aforedescribed o -sit g
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the syst m in o e a Q T
Certificate of Compliance has been iss b this Board of alth. @ °
Signed , i..._- Date
Application Approved by � Date
Application Disapproved for e following reasons
Permit No. 7�` S Date Issued
THE COMM NWEALTH OF M SSACHUSETTS
AL , MASSACHUSETTS
% erlutr x#e of V..=1311auxe
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed ( ) or repaired/ replaced (_'p) on
/ Z. —/. 7 - �5 by �l G� � �?i2-C S . for S/� '- "Z- 771
at g 0L�->-S-7- has been constructed in
accordance with therovisions of Title 5 and the for Disposal System Construction Permit.No. q� 7�� dated
/-2 ,/ — Y 1_:�_ . 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 expires on
DATE Inspector 1 T