HomeMy WebLinkAboutApp-Permit-ComplianceNo. � — Q FEE
THE COMMONWEALTH OF MASSACHUSETTS
'ti° `J MASSACHUSETTS
cIyyfi ativu for Ptislavent Sgstem (f.oustrurtion ]Jrrutit
Application is hereby made for a Permit to Construct ( ) or Repair (L -Kan On-site Sewage Disposal System at:
Location Address or Lot No. 0.�,jtt
Owner's Name, Address and Tel. No.
4-7
s�j��� a ✓Tvi
Installer's Name, Address, and Tel.No. -2 2 — :E
Designer's Name, Address and Tel. No.
/W- 30 2 8 2 ��
Z3� Grz,WoSi�rxrJ ��-✓,�'is �3�b" Z
Type of Building:
Dwelling
Other
Design Flow
Plan Date A
Title IVA
No. of Bedrooms Garbage Grinder (Xo
Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
1/,19 gallons per day. Calculated daily flow 370 gallons.
, J ;/ /!7/-!;- Number of sheets Revision Date
Description of Soil —
Nature of Repairs or Alterations (Answer when applicable)
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 ' ed b his Board ealth. /
Signed Date C®
Application Approved by Date
Application Disapproved fort the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
1/,ifrL�TJT�` , MASSACHUSETTS
Certtttrate of (gonty Came
THIS I O CERTIFY, that the On-site Sewage Disposal System installed ) or repaired/replaced" on c�
s--, by s1 5 `>/9svi _5 �7� vires foryly,�rii-- /955!�Zvti�2i
at /ver ' �/ - `? /fY�/!ily�i has been constructed in
accordance with the provisions of Title 5 and he for Disposal System Construction Permit No. /6 -Z22 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
DATE 3 �� 6 Inspector .' v/f