HomeMy WebLinkAboutApp-Permit-ComplianceNo. Fee 49775
THE
// COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
, Vpfir attun for Viepasal �$gstem Tonstrurttun jhrmit hoJ
Application is hereby made for a Permit to Construct ( ) or Repair (P'�an On-site Sewage Disposal System at: grill.
Location Address or Lot No.
Owner's Name, Address and Tel. No.
ohn A/4',-
j,,�;7'
Installer's Name, Address, and Tel.No,Designer's
775-7`f
Name, Address and Tel. No. .. i7 G S`j' b'
-�sc /0, rw=.
Type of Building:
Dwelling
Other
Design Flow
Plan Date
Title
Description of Soil
e � i
No. of Bedrooms
Type of Building
Other Fixtures _
?30
W1
Garbage Grinder ( )
No. per Persons
gallons per day: Calculated daily flow
of sheets
Showers ( ) Cafeteria( )
d gallons.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewa a disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the syste ntil a
Certificate of Compliance has been isWedby th's Boar of Health.
Signed Date1��
Application Approved by Date
CHAPMAN
Application Disapproved for the following reasons _
f(I
Permit No. —e-0 _12 / 1 ! L`/"U° Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
(/.. e"z--77ii , MASSACHUSETTS
( erfifirIte of Compliance
'T/FY, that the On-site Sewage Disposal System installed ( ) or repaired/ replacedJ_iC) on
7 . a .e ksvSi — for !
at ryc - eY f i �0/Az%t-= !!®AA �61 has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �`^°`^ dated
?-�3`�rY . 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