111 Application & Permit 1995 ./ 7
THE COM
ONWEALTH
FEEfi57
F MASSACHUSETTS
cAppliratiun for !ispus
MASSACHUSETTS
It !ystem @lanstructiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair( )an On-site Sewage Dispo al System at:
Location Add�us or Lot No.
LOT# 'j$
/// uJ-L7/a2
Owners •'a e Addre a el No. !'L%6g?j
O
',i .�. /-
h14- o;o73
V /-
Instal iam- ddre .•r -I Na. ,jZ/a W9S
rr / r #u-- D/OZ7
Delia Ad�!s and TG.wo.
i
3
... �� OIDLD
Type offuilding:
( we lin No. of Bedrooms
Other Type of Building No per Persons Showers( ) Cafeteria
Other Fixtures
Garbage Grinder(up
Design Flow Agf9 gallons per day. Calculated daily flow—
Plan Date / Number of sheets a--_ Revismp.pme
Title 1 lW�"_'� $ -
1- o —V `, SuR't Swc,JJ 54 "-- 36 " !filed -doeviCeSse
gallons.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 1Fl. issued b c o of Heal
Signed
Application Approved by
Application Disapproved for the following reaso
Date 8/3/9 3-
Date gill
Permit No
Date Issued
THE COM/ONWEAL11 OF MASSACHUSETTS
MASSACHUSETTS
f "
Certificate of Compliance
/70-1 9rf$ TO CERTIFY7ltbatfhp pn/shg Sewap Disposal System installe y)orfeepairedl replaced( ) on
//i y xl - v for U ,w,._
( /-e F ' ha/s beep strutted in
cpgo Q4pceirp-Ebe 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
:ertificate expires on �//`r- /'
SATE q' Inspector
THE C MONWEA H OF MASSACHUSETTS
Vo. •l — / S / r 77'1'1 MASSACHUSETTS FEE
!iSposal $uStem (Construction Permit
Permissionjs hereby granted to �z ( �
o cote truct f ,) or rgpair p)an On,stte Sari,Systeat loeat d at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
luty to comply with Title 5 and the following local provisions or special conditions.
411 construction mpst be completed within two years of the date below. t /
DATE j=�'-4-r_t / / lj `J Approved by �-L
oRM 1255 Rev 3/e5 nM SULKIN C(_eos DH.MA