HomeMy WebLinkAboutApp-Permit-Compliance1 7 -
No. �)' FEE �S
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
cNyylirattnn for Pisyveial,,Sgstent C onstznrtion Ilerrait
Application is hereby made for a Permit to Construct ( ) or Repair (V�an On-site Sewage Disposal System at:
Location Address or Lot No. Z 0-� r -Z A/ � �/
Owner's Name, Address and Tel. No.
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Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
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A/J? 0Lp 'KNI?ti3Oki4 KV
R v)VAY4-4 C ltpoLL�G
if -/-ti'R3�s.,Bo��j
1112
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Type of Building:
Dwelling No. of Bedrooms Garbage Grinder ( )AIV
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow, gallons per day. Calculated daily flow y110 gallons.
Plan Date Number of sheets 2-- Revision Date
Title R Zc4o4./ 7%2-V5i22 47"' Col -2? S 9 60VR- 'z-n/k� W41f-% 4
Description of Soil OCL /&!j
Nature of Repairs or Alterations (Answer when applicable) %S0 G-fes—JZ*-
4-8
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 pro"' ' nsoffitlq�5 f the Environmental Code and not to place the system in operation until a
Certificate of Compliance has en ' sued ar of Health. /
Signed Date
Application Approved by Datele
Application Disapproved for the following reasons
Permit No. g - ��2^ Date Issued 5z
THE COMMONWEALTH OF MASSACHUSETTS A -e- `e -S
eri�T7/ , MASSACHUSETTS _o/C:
(E.ertifir xte .v# ( MYtinure
THIS IS TO ERTIF Y, that the On-site Sewage Disposal System installed ( ) or repaired/ replaced (') on
11 u by —A& a t L-,AI_kPfor IZA-Ado e pA ,moo/
»° at 7 9 vl��h t;ZI�711 has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. X15 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 functoil as designed. This
Certificate expires onR
DATE t Inspector - �� t