276 Application & Permit 2002 No. S. .3—
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ACHUSETTS
ASSACHUSETTS
FEE
cAppiication for Pisposttl (*got= Construction Permit
Application is hereby made for a Permit to Construct QO or Repair( )an On-site Sewage Dispo al System at:
Location Address or Lot No.
Z.% T�.ex��tc �o4b
f,,,f-(J�
Owner's Name,Address aged Tel. No
t,CHR,e1 56A P ��-s�� ,
Po teox p6
Arai S rA'4Jfl -ro.✓
Installers Name,Address.and7t1 No
guar's Name, dres dTe N
44 R;? t
ensrN4mIYON Inn 527-J 290
WM'rezdy 4 c, k r .ve
ib/¢PC e- Sr 6z�-1321
Sov-r-/Avoi/ren!/04
Type of Building: 3
Dwelling No. of Bedrooms
Other Type of Building No per Persons Showers( ) Cafeteria( )
Other Fixtures
Garbage Grinder(K)
Design Flow
Plan
Date
Title
5Ss
gallons per day, Calculated daily flow �J
LF/2,5-10 7 Number of sheets 1 Revision Date
Dui # zoo2- 09
Description of Soil
gallons.
r 12OWS s7 nwaS
a
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
non
�i • a
Agreement:
The undersigned agrees to ensure the construction and maintenance of the af redescribed on site sewag?ttleposet
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 sBBoard iof Health.
ss
Signed
Application Approved by
Application Disapproved for the following reasons
Date
0
Date
Permit No Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
7 MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed(P1 or repaired/replaced( )on
/0 •// —OZ by Pie/N/TV`t-/ r-. z. -... � for /:'•:, _
at 2. '26 c,% / '°< F >,=0 has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No S- 02. dated
-BG - oz 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 s stem will function as dp ned. This
Certificate expires on
DATE /0 - // Inspector
1,- G
HE CO ONWEA, TH OF MASSACHUSETTS
No. � '' Pe)E 25`)44' MASSACHUSETTS Fee
Pisposttl gi(stem Construction Permit
Permission is hereby granted to t.C'V' LC.'.v �-�'rN :77
to construct or repair( )anOlsite Seta e S stenylocat at /
,C ( !G.�.. ''-Cgj, y j-/ -.1..'ed/' \
and as described in the above ApplicationtThr Disposal System Construction Permit. The applicant recognizes hisi her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
DATE (/" /9 .?! %- Approved by
FORM 1255 Re.3,95 AM.SUUON C-BOSTON uA