1057 Septic Application 1051 No7-76
THE COMMONWEALTH OF MASSACHUSETTS
GTYOt APer 'nPrOA) MASSACHUSETTS
FEE
■pp1irnItiuit fur !ispuzal $gstrm Constrttrtiuit Permit
Application is hereby made for a Permit to Construct( )o Repair(A an On-site Sewage Dispo al System at:
Location Addrexa or I at Na_
/05/ Chrile 4
In ler's Name.Add eu and Tel No
PaS( O.9-L/ M/ ntskit), ,
Owners Name.Eddress'd Tel.No.
e namii]�A d Q f l7 T4y-0 5.5-C
Deagnerz Nome:Address and Tel.No.
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder( )
Other Type of Building No per Persons Z Showers( I Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily Bow gallons
Plan Date Number of sheets Revision Date
Title D
Description of Soil / 2A1{
Nature of Repairs or Alterations(Answer when applicable) lee/4__ 4''t ,rt///, 5-6-4 71,c- 7‘741,E
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
Signed Certificate of Compliance hd¢bee issued by t toard of Health. _
✓,a eras Date �%�
�/ ra Date 6
Application Approved by
Application Disapproved for the following reasons
Permit No. 37-76
Date Issued