27 Application & Permit 2002.t • r; Ole a I _ us
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THE COMMONWEALTH OF ASSACHUSETTS
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Application for Pismo! (*gstem Construction Permit
Application is hereby made for a Permit to Construct.X) or Repair( ) an On-site Sewage Dispo al Sy € n at:
tocauon Address or Lot No. �y[
27 .�R i L IAM' 2°T" 1
Owner' Name,Address and Tel.No. /:'V Wv 3 oL
MA 7 ni.epte er X85- Bp d ZS
FLO2671/CC »i4
Installer's Nape,
a
��`
Address,andTeLFO.
4,fl f4
) 1
�T7
,vu
r
Designers Name.yddre dTel No Cie
,a4 1r ry • a- MACIA,
996t& PACT Sr
et'''. mA 5-27-,x290
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
5-49
3�L9102
Design Flow
Plan Date
Title Hi r-1 ZOO Z. — 0�D
3
Garbage Grinder(X)
No per Persons Showers( ) Cafeteria( )
gallons per day. Calculated daily flow
Number of sheets
Descri lion of Soil
— So
493-
Revision Date
gallons.
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected.
Agreement:
The undersigned agrees to ensure the construction and maintenance of the a oredescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of lye Environmental Code and not to place then tem ingperation untila
Certificate of Compliance has be issued by this rd of Health.
Signed V aAt�Application Approved by
Application Disapproved for the following reasons
Date
y
Date
Permit No Date Issued
THE COM1}MONW EALTH OF MASSACHUSETTS
,//4.7t,-n%- ,!4,.e' MASSACHUSETTS
&ertiffrate of Compliance
THIS WO CEyR TIFTothat t fie an-sjte Sewag�£'Dispord Sytstgm installed( ) or repaired placed ( )on
at I h &c c_ has been constructed in
accordance with tftee plovtstons of Title 5 and the for Disposal System Construction Permit No y` C �� dated
4/� D ('.� Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificatpf shall not t7 as guarantee that the system will function as designed. This
Certificate expires on '-/'' /
DATE /e 1 "")!`l " Inspector4:24"5 c /�'�-iile_s et.L
IA- - --
THE COMM NWEALTH/OF MASSACHUSETTS _ , ,
/ .. /5 /
No. ��/ QOM !�D/J/MASSACHUSETTS FEE
pisposol _gstim Construction Permit
Permission is hereby granted to �y�-a-> e t. Lc 5
to construct(X) or repair( )an On-site Sewage System located at
-) / 7-; i ac4t
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.
'^/etc
All construction must be completed within three years of the date below.
DATE i
l- 7.273-Z Approved by
FORM @ti Re.3/95A. SULMIN CO—BOSTON.MA
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