613 Application & Permit 2003 No c;ThJ ^4)--)
FEE
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
ipplicatinn for !ispnsal ,$gstem Construction Permit
.pplication is hereby made for a Permit to Construct ( ) or Repair( )an On-site Sewage Dispo al System at:
a
Loearon Address or Lot No.
( J3 wLSvhke-iv/Dn a
Owners Name,Address and Tel.No.
50 bp I Ck PrA vie MurbJ
In
Anfhun�/ (,ahn - �F "�
710 b4nio Sh..ys 4*')y Kinar,m
Designer's sNNamme,Address and Tel /
No. �t 1
/ '/ /A- ) ltri q
Type of Building:
Dwelling No. of Bedrooms 3 Garbage Gr N jder )/
Other Type of Building No per Persons Showers(c2 ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 415'5 gallons
Plan Date Number of sheets Revision Date
Title V/�
Description of Soil /
Nature of Repairs or Alterations( swer when applicable) +a /�t l rnn 01 lt.U2
.--e0 O
Date last inspected /a-o ft-3
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 een issued by this Board of Health.
Signed } it-/`e/ -4' n 7 '°/61'3
6 /� Date
Application Approved by
Application Disapproved for the following reasons
Date
Permit No
Date Issued
THEE COMMONW@ALTH OF MASSACHUSETTS
/tee tl/�_ ,MASSACHUSETTS
Certificate of Compliance
f O CERTIFI . t t:e On-s'•• Sc .�•- Disposal System installed, ) o[rep X /re red ((Xon
--,� �by 3 ` . r . - ai,6� for — c..- v' ria.F'4if^'
at h been constructed in
accor¢ar #wkh the provisions ti
Title 5 a d the for Disposal System Construction Permit No. 3--0 3 dated
(/� j/qa . Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate all 15 construed as a guarantee that the system will function as designed. This
Certificate expires on 72 / / /
DATE .N �'/ 1 Inspector A=�'
0 THEO MMONWEAETH OF MASSACHUSETTS 90�, _.
No.
"�S—� 5 NG'� t. 7 � , MASSACHUSETTS FEE
!isposal $gstem Construction licrmit
--�; -` ii. 7g2r :( < '•Permission is hereby grant to / (p/ �� .. �,
to construct ( ) or repair( 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.
• ice'
All construction roust be completed within two years of the date below. y.i '—` - z
,. ti t,,,,-____( --- ; ..c.
DATE p�� L��`-t U ` Approved by r/ f 17 .
FORM 255 R .9951 „ran Co-BOSTON.MA