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THE COMMONWEALTH OF MASSACHUSETTS
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Y R-1ZmD V l i -i ,MASSACHUSETTS
41ppliration for Pisposal ' *4gstem C onetrurtion fermit
Application is hereby made for a Permit to ConstrV ( ) or Repair ( ) an On-site Sewage Disposal System at:
Location Address orLot No. Pryy1 z (p H 53
-13 k) ST' Yg2.Y+'►c. ZJ D
Owner's Name, Address and Tel. No.
JOHN O'S'ULA-1VAJ,
\00 ETS 1 \I I -Z O ON rYl t4
7 3 W ES T N1 A r M p "T H Rd
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W OZ
Inst ame, dress d Tel.No.
`� � -t 7-Z'C>_J Z �
Designer's Name, Address and Tel. No.
R . i . C as I
80X ZS$ VIVIA O Z 6 7
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Type of Building:
Dwelling No. of Bedrooms 3 MVIi�U. Garbage Grinder (lid
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow 3-4-5 gallons.
Plan Date ( L?4 1 5S Number of sheets Z Revision Date �-
Title S 17 E P 1 Arry t=o rz J o H:&2 O ,So l -L 1 u.M,, Lo i' 5:? "7 3 w . Y�Lm
Description of Soil oA-v►1�. .fAvti-�,( �-{ G�• ,f��.� (—see
Nature of Repairs or Alteratipns (
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 'tle 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been iss this Board of Health.
Signed Date
It
Application Approved by Date
Application Disapproved for tyle following feasons
Permit No. /� / Date Issued
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THE COMMONWEALTH OF MASSACHUSETTS
y F1 rn o J -T H , MASSACHUSETTS
49.ezkt#trate of Conry ian e
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed ( ) or repaired/ replaced (X) on
J Y� by for j c H k� 0- S v t.4_t vA-"
at 7 3 W C75-1 fR fn t (5 `ir1 N IZd • has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. `%S- 71!% 'dated
/2 - /3 �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 ��� , 1. «.
DAT �� Inspector,