136 Septic Application 1998 471( LYa
FEE
THE COMMONWEALT OF MASSACHUSETTS
Nor
cliaplication for !isvos
MASSACHUSETTS
1 *getem Construction Permit
Application is hereby made for a Permit to Construct ( ) or Repair( )an On-site Sewage Dispo al System at
Location Address or Lot No „���
/3 � ch tier fTf
Owner s Name.Address and Tel. No.
—k i k an�r Clet a .
Installer's Name Ad ss.and Tel No. Designer's Name Address and Tel.No.
odtrill-
Type of Building: 3
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow
Plan Date
gallons per day. Calculated daily flow
Number of sheets Revision Date
gallons.
Title
Description of Soil
Nature of Repai Alterations(Answer hen ap..icable)1
e IQJ
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 been issued by this Board of Health.
A<Signed
Application Approved by
Application Disapproved for the following reasons
Date
Date
Permit No Date Issued