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THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
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Appltratio t for Pielavent,*Votent vivatrurtion 1hornfit'
Application is hereby made for a Permit to ConstructT ) or Repair (• an On-site Sewage Disposal System at:
Location Address or Lot No. w ' , j (
Owner's Name, Address and Tel. No.
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Installer's Name, Address, and Te1.No.
Designer's Name, Address and Tel. No.
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Type of Building: .
Dwelling No. of Bedrooms Garbage Grinder ( )
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow 3�a n gallons per day. Calculated daily flow -33-51- gallons..
Plan Date - S ft 7 Number of sheets Revision Date _ a l',i 7
Title 1N�c. vy-nN
Description of Soil _- L OW ^ `1 SO+AO vv--' Slawo
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 o he Environmental Code and not to place the system in operation until a
Certificate of Compliance has bee j6d by I oa of H
gned Date
Sib-10-57
Application Approved by Date Z; 7
Application Disapproved for the following reasons
Permit No. 7'- C�`ZL ; Date Issued '�' `6^ 9
THE COMMONWEALTH OF MASSACHUSETTS
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THIS IS T_ CERTIF that theOn-site Sewage Disposal System installed(✓) or repaired/replaced ( ) on1°y.
�J,•��'.CJ by V1(J-C44PE SEAT\� for �arroN
at has been co tructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _ dated
G 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 TncnPntnr //4-