HomeMy WebLinkAboutApp-Permit-ComplianceNo. S— 7�✓ FEE
THE COMMONWEALTH OF MASSACHUSETTS
Z/ or lid G,MASSACHUSETTS
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41pplirattun for Disposal �*gstem C onstrurtion 11ormit
Application is hereby made for a Permit to Construct( ) or Repair ( ) an On-site Sewage Disposal System at:
797 1
Location Address or Lot No. Owner's Name, Address nd Tel
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder ( )
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 0440 gallons.
Plan Date y _ �Q' S Number of sheets / Revision Date
Title
n of Soil ' �' '1' SL % `� ' t (� �� - `7
Nature of Repairs or Alterations (Answer when applicable)
Lt", i _rij 13 ` .Sro� 1 ' tr �-ra.4? ik
Date last inspected:
/
Agreement: /
The undersigned agrees to ensure the construction and maintenance of the aforedestribed 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 been issu by this Board of Health.
Signed Date
Application Approved by Date
v'
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS %�:�CL' : L� \!` ��'•
4-
L/AR 64 GVTP I -,MASSACHUSETTS
Certifirate d Gintylianre
THIS IS TO RTIFY, that the On-site Sewage Disposal System installed ( ) or repaired/replaced ( ✓ '(
2 /S - 9�y �e. 4UOp L30 for
at has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.� dated
�� -A - �S . 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
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I
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Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
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p(� C
;? F_ fc?,o M El n A f 6
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder ( )
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 0440 gallons.
Plan Date y _ �Q' S Number of sheets / Revision Date
Title
n of Soil ' �' '1' SL % `� ' t (� �� - `7
Nature of Repairs or Alterations (Answer when applicable)
Lt", i _rij 13 ` .Sro� 1 ' tr �-ra.4? ik
Date last inspected:
/
Agreement: /
The undersigned agrees to ensure the construction and maintenance of the aforedestribed 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 been issu by this Board of Health.
Signed Date
Application Approved by Date
v'
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS %�:�CL' : L� \!` ��'•
4-
L/AR 64 GVTP I -,MASSACHUSETTS
Certifirate d Gintylianre
THIS IS TO RTIFY, that the On-site Sewage Disposal System installed ( ) or repaired/replaced ( ✓ '(
2 /S - 9�y �e. 4UOp L30 for
at has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.� dated
�� -A - �S . 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