HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
THE COMMONWEALTH OF MASSACHUSETTS "
% MASSACHUSETTS t�
(�XyyXtrativn for Pioposal Sgstem Construrtion Ilerrait
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an On-site Sewage Disposal System at:
Location Address or Lot. No
O ner's Name, Add r ss and Tel. No. J�
Installer's Name, Addre s, and Tel.No.
�/ctAvJ , , )1-iI'ss1r.�
Designer's Name, Address an Tel. No.
9 3�� AA,gb� Ad
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder ( )
Other Type of Building 6lna1CCA—+I+1 No. per Persons — q Showers (a) Cafeteria( )
Other Fixtures
Design Flow qqD gallons per day. Calculated daily flow gallons.
Plan Date Oef a (o 19 S Number of sheets Revision Date
Title
Description of Soil - fM/r /
Natur of Repairs or Alterations (Answer when applicable)—JOnx '% '36 "V-.2
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 be issued by this Boar of Healt
Signed C-- Date
Application Approved by Date
Application Disapproved fort a followin reasons
Permit No. / Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
(gree trate of Graylianre
THIS IS TO CERTIFY that the On-site Sewage Disposal System installed( ) or repaired/ replaced .(.) on
2i: by dam@/ �/ C' iss c i�t/r^— for �%�J> .77401 ZZY /f/%. -'
at has been constructed in
accordance with the Provisions of Title 5 and the for Disposal System Construction Permit No. 9/ :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
r
DATE 7 3 % Inspector