111 Septic Application & Permit 2000 THE COMMONW E,5}TH OF MASSACHUSETTS
NaPS
MASSACHUSETTS
FEE 30 en
cAppiiratiun fur !ispnsat System Construction Permit
Application is hereby made for a Permit to Construct ( ) o Repair(Xl an On-site Sewage Dispo al System at:
Location Address or Lot No.
It ! 'u
Owner's Tel.No. L4rt°
ltilr�-�
Installer's Name,Address,and Tel.No.
A,C'13 1S ,f.1,,., 037-ct4
Designer's Name.Address and Id.No.
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building No per Persons Showers( )
Other Fixtures
Garbage Grinder( )
Design Flow
Plan Date
Title
Description of Soil
Cafeteria( )
gallons per day
Number of sheets
Calculated daily flow
Revision Date
gallons
Nature of Repairs or erations(Answer when
ap licable)
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 has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No
y5
Date Issued
7e - 7-07)
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
Certificate of Compliance
77175 IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired?replaced( ) on
by ,. for
at has/been constructed in
accordaq_ce_wit the provisions of Title 5 and the for Disposal System Construction Permit No dated
Use of this system is conditioned on compliance with'the provisions set forth below:
The issuance of this certifies te shall not be-construed as a guarantee that the system will function,as designed. This
Certificate expires on
r
DATE J r Inspector
_ THE COMMONWEpLTH OF MASSACHUSETTS
No. yG� t/L' /�,j �� MASSACHUSETTS Fee
iDispasal (*totem Construction Permit
Permission is hereby granted to
1
mite�4e�ye System located an
tostAanwsn ,) or want(
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 construction must be completed within two years of the date below.
DATE Approved by
FORM 1255 Rev 3/95 P M.SU N N CO.•BOSTON.MA