40 Septic Application & Permit 1997 No
/7- 27
THE COMMONWEALTH OF MASSACHUSETTS
/- r� ?—{h1Wio-rbiJ MASSACHUSETTS
Application for !Disposal Systrm &instruction Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( an On-site Sewage Dispo.al System at:
Loealion Address or Lot No
kir aofur
O r i Name,Address ands Tel N0.
/�,4ern/ /I (' CkO / Yo duu0-lv oe
LJoe /7,,4,4p7hJ 0119 Ss‘ s,4
Installer's Name.Address.and TeINo.
Type of Building:
Dwelling No. of Bedrooms
Other Type Si Building No per Persons Showers ( ) Cafeteria( )
Other Fixtures
Design Flow Li tj U gallons per day. Calculated daily flow 3-9)0 gallons
Plan Date S//Sit;7 Number of s Bets t/ Revision Date
Title 1J2 �)% I ',LI t0IP
Designers N Address'end
*- ��NtE elan
T7 yrcori ACT
oc /rue. l ' 6
»f-/ /11N Lj[? 7zaR
Garbage Grinder( flf 4I(We
Description of Soil
1 L• -- 1 G O
Nature of Repairs or Alterations(Answer when applicable) e a' `.
111 %'fA.+6' /,6.
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 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance s been issued.by this Boast] of Health.
Signed - ' y h/l r2Ys4.. , F�'Z L.-',F�—` I.B_,� --a-Date 5/12747
as., !/i Date —/ii /77
Application Disapproved for the following reason
Application Approved by
Permit No Date Issued
THE?Or MONWEALTH OF MASSACHUSETTS
NU/titA,1 Ji nKJ MASSACHUSETTS
&ertifirate of Compliance
THIS IS TO CERTIFY that the QQn-s to Sew"ages Disposal System installer or re�.ired e.laced (yO on �%
by I.t?ONo-Vd APB.-c..q for • 4- r
at ✓p (-It_t 0 N Ii 7 017 has b n constructed in
accordance wittty'e rovisions of Title 5 and the for Disposal System Construction Permit No dated
%r/ � Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shay npt be construed as a guarantee that the system will function as designed. This
Certificate expires on /`/;
DATE Inspector / - r / r /v_l t/-- ..r(.
'°"'! (/72K7
THE COMMONWEALTH OF MASSACHUSETTS ,
No /1-17 /660.7&-hLIt117bli MASSACHUSETTS FEE
pispnsal to Construction !ermit ,
Permission is hereby granted to ( /",/,� / f t'. el*
to construct ( )or repair O )an On-site Sewage System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his her
duty to comply with Title 5 and the following local provisions or special conditions.
All constructio st be completed within three years of the date below.
�
DATE s / � J /-74// Approved by f —�-
FORM 1255 Rev 396 A.M.SU IXIN CO.-BOSTON.MA