Appliaction & Permit 1998 THE COMMONWEALTH OF MASSACHUSETTS
/JO477- P TV J MASSACHUSETTS
,1pplicatton for !isvosal *velem Construction Permit
pplication is hereby made for a Permit to Construct(X) or Repair( )an On-site Sewage Dispo al System at:
Owners Name.Address and Tel.No.
lco,,gyL Coa nnzucr7o,j
-51 C.4MPk5 PM-34- AMO$)Z.ST Y1h
K/4- 25-6- 0321 / /
Inslellers Name,Address.and Tel No Cot es. CLOG Ta+1f Designer s N Address and Tel.No.
e1.A
SgsGA-1C S577 �.(DC ,r=*
,/±75±7
I ocation Address Or Lot No.
9A. th ,t'/S Co/loos, J
Dasw Cg IPOAD
'vpe of Building:
Dwelling No of Bedrooms Cafeteria( )
Other Type of Building No per Persons Showers( )
Other Fixtures \ p �5
)esi Flow 9900 C1 �/ gallons per day. Calculated daily flow el bl,/ gallons.
gn 9 Z3
Nan
ca an Date 7/6/15 Number of sheets V Revision Date
Title SePTZC SYSTEM /.M/nuT Pl At.) ADD/776444-f 5
/Description of Soil <FP PLrwS
12 (GOO b e3/oA) Garbage Grinder( )
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected' N/i4
Agreement:
The undersigned agrees to ensure the const uction a
system in accordance with the provisions of Title 5 ofthe vir
Certificate of Compliance has been i.(ued by this Bpard H
C� igned
Application Approved by i
Application Disapproved for the following reasons
maintenance of the aforedescribed on-site sewage disposal
mental Code and not to place the system in operation until a
Ith. /iv / fig
71/
Date
Date
Permit No
Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
.\( T7 44- ,:-( MASSACHUSETTS
Gtertifirate of (Emnpliunre
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( )or repaired/replaced( ) on
j-.1 /<Li,. .f, ..ir<)5,•-J. � FT'oltr0Cca fcL.f-
it has been constructed in
accordance with 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 certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE Inspector
No. l
THE COMMONWEALTH OF MASSACHUSETTS
/'( MASSACHUSETTS
!isinf Sustem ccoz}$trurtion lrrmit
( HJp C (L 64- E-Kri
Permissiop is hereby granted to
to construct( i of€epair(,,) On-site Sewage System located at
FEE
' 1rryl
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 condit ns.
All �construM pm p le d wi f of the dale below. /> ��it,G .
DATE eDi .Approved w. L _
FORM 1155 Ra..B.95 A M SULKIN CO-BOSTON MA
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