HomeMy WebLinkAboutApp-Permit-ComplianceNo./�0
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THE COMMONWEALTH OF MASSACHUSETTS
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Application is hereby made for a Permit to Construct ( ) or Repair (VI/an On-site Sewage Disposal System at:
Location Address
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O,wjneer'ss�Naame, Address and Tel. No.
Installer's Name, Addr s, and Tel.N
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Designer's N me, Address and Tel. No.
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Type of Building:
Dwelling
Other
No. of Bedrooms Garbage Grinder
Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow ,,jallons per day.
Plan Date �J Number of sheetr
Title
Description of Soil
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
Calculated daily flow
Revision Date
gallons.
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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 th�oardof.
Signed Date 2 ---
Application Approved by Date
Application Disapproved fo the following reasons
Permit No. �1S— 7 Date Issued 8
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THE COMMONWEALTH OF MA �SACHUSETTS `
1 MASSACHUSETTS
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THIS IS O CERTIFY, that the On-site Sewa a Disposal System installed ( ) or repaired/replaced ) on
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at AP4f has 4en constructed in
accordan wit��pr�is�j of Title 5 and the for Disposal System Construction Permit No. T= —&%K 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 `�