392 Septic Application 1995 No
ac9-9S• -
FEE 60'_
THE COMMONWEALTH OF/MASSACHUSETTS
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L Y 012-7771/9 ,O To/t) MASSACHUSETTS
pplirattun for pieppSal System Construction Permit
Application is hereby made for a Permit to Construct ( ) o Repair(X)an On-site Sewage Dispo al System at:
Location Address or Lot No.
392. CHESrEr2F/el-D izOAb
Owners Name.Address and Tel.No.
NAKrzy LetsH404y
Se4-334-5
Installer's Name.Address.and TeI.No.
Designer's Name;Add Addrus and Tel No
Slam ES . t 9C,4, PC
49 EN�1Lc•!7j E'ranJ
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527-52-90
Type of Building:
Dwelling
Other
Design Flow
Plan Date
Title
No. of Bedrooms 3
Type of Building
Other Fixtures
Garbage Grinder(X)
No per Persons Showers( ) Cafeteria( )
5-40
Description of Soil
gallons per day. Calculated daily flow +9,5
/O! 12 J9r Number of sheets
SEPT/c 5ysTeM 2sfe/ie_
5tt So,t to o ?no , #
Nature of Repairs or Alterations(Answer when ap
C, C LEA Cr
•
Revision Date
gallons
/D
icable) /e6-10.#51,09.— 5Eic C
E
4010
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 bee ssued by this Board of Health.
A 4 ICS Wed
pipeti
Signed
Application Approved by
Application Disapproved fo
Date
Date
-.)-41--5 1--
he following reasons
Permit No Date Issued
6'