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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 9i 5� FEE � B G THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS c vlayfi ation for jBispoeal **stent Tons#rur#ton p.erntit Application is hereby made for a Permit to Construct( ) or Repair ( ) an On-site Sewage Disposal System at: Location Address or Lot No. 6/ Owner's Name, Address and Tel. No. 3 ^ 7/8?— r►o! c. c. -74Cal1CcT/a /✓C ✓�- .► a�b 7S/1u�3 /O�AO A11V = ._ Al vFk Installer's Name, Address, and Tel.No. Designer's Name, Address and Tel. No. 7;Jd1%/ ice, 44 Type of Building: Dwelling Other No. of Bedrooms -� Type of Building Other Fixtures Design Flow Z 3<3 gallons per day Plan Date Title Garbage Grinder No. per Persons Showers ( ) Cafeteria ( ) Calculated daily flow a 7 ;?, -7 S— gallons. Number of sheets Revision Date Nature of Repairs or Alterations (Answer when applicable) • i /' •CX T sO ••7C—Jl_).e 1..Lr r i/ / ,l. c. .?n..A /1_. ?—_�n/1/r11� LFasf'!-� �I�!/ay1s?sc''�PS :)[ W4, -!c' ©,a� `_L%6/VC C) ^-/ 14L[, eJ /!UV'+.1 6`7-7Y /V6tV PSOCI AeX A/V^A+C M Z74 - Dat e 4 - 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 been issued by this Board of Health. Signed / Date q Application Approved by Date i Application Disapproved for the following reasons , Permit No. ��— 9j:2 Date Issued / THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS Certificate of Toraylinure THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ),pr repaired/ replaced (k) on 4c /� ` by L z L LS D'AOS for ,/Y- L T at ?Z C&A sr. �, �r f - .�srr�t has been constructed in accordance with he rovisions of Title 5 and the for Disposal System Construction Permit No. g`1 "-� 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 expires on f DATE Inspector THE COMMONWEALTH OF MASSACHUSETTS No.MASSACHUSETTS FEE S-0' ptsy"osttl �5Vstem (2101ts#rurtion P.errait c Z Permission is hereby granted to f to construct ( ) or repair (,)o an On-site Sewage System located at %Z��is7�tir ✓'C and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. 6 ✓ eS. All construction must be completed within tby.,ti_-yRAaqf the date below. DATE (� Approved by FORM 1255 Rev. 3/95 A.M. SULKIN CO. - BOSTON, MA