HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE /910D
THE COMMONWEALTH OF MASSACHUSETTS
J--1 MASSACHUSETTS#
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Application is hereby made for a Permit to Construct ( ) or Repair ( an On-site Sewage Disposal System at:
Location Address or Lot No. // j�
Owner's Name, Address and Tel. No.
eC
Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
Design Flow 1 �� ew/ allams per day
Plan Date Z&yd —2 , % �P�f� Number of
Title 57,-A1_/X411 _70h k rata �
Description of Soil
e K
Garbage Grinder (91)0
No. per Persons 9 Showers ( ) Cafeteria ( )
b of Repairs or Alterations (Answer when applicable)
Calculated daily flow
S 3 6
Revision Date
Seymoric
gallons.
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
of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has n 'sued rd o Health.
Signed - Date /� -S
Application Approved b Date
Application Disapproved for e followin reasons
Permit No. 7_-7 M Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Afzmo(-, �N, MASSACHUSETTS
Gertifir- to of 010my inure
1q
THIS IS CERTIFY, that the On-site Sewage Disposal System installed( or repaired/replaced ( ) on
by "� +A -AA V5 ci � V—e;,-.^ for "� f� � -t �=:�� j,% .� S _
I at ! ;s' >- �\- has_been constructed in
accordance the
provisions of Title 5and the for Disposal System Construction Permit No. dated
(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
L
DAT)✓ 7-9`5Inspector f