HomeMy WebLinkAboutApp-Permit-ComplianceNo. - FEE
THE COMMONWEALTH OF MASSACHUSETTS �' l
MASSACHUSETTS
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Application is hereby made for a Permit to Construct (; ) or Repair (D�_.an On-site Sewage Disposal System at:
Location Address or Lot No. ,//fP Z�
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In er's Name, Address, and Tel.No.
De ner's Name, Ad re and Tel. No.
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Type of Building:
Dwelling No. of Bedrooms ''A Garbage Grinder (fit *1 Q
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow A" gallons per day. Calculated daily flow gallons.
Plan Date `��� %4,6— Number of sheets l Revision Date
Title
Description of Soil --
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Nature of Repairs or Alterations ``Answer when applicable) • I � � � `�
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Date last inspected:
Agreement:
The undersigned agrees to ensure the construction a 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 Wed try this B rd Health.
Signed Date
Application Approved by Date /2 -/Z _7
s
Application Disapproved f r the following reasons
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Permit No, -" Date Issued
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THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
C9ertif rate of Cgontyli ur-C
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/ replaced (Aj on
by U/t.`Tl�tA E7 C �JSr',�`�! CX7 u "1 for
at cf t L -s -4-4 LAI has been constructed in
accordance with the provisions of Title 5 and the for,Disposal System Construction Permit No. 2S- ZQFZ 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 `������ Inspector -