501 Septic Application & Permit 1997 THE CrONWEALhil OF MASSACHUSETTS
FEE
NCr MASSACHUSETTS
pptiration for pi$posal $gstrm Toristrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair(:)an On-site Sewage Dispo al System at:
Loc�Mqer�aL�L'M �,��i�- r
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Ind SJ( a e,�adrado l.No.
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Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
F. 3 0
Design Flow
Plan Date
Title
Description of Soil
Garbage Grinder ()--
No per Persons Showers( ) Cafeteria( )
gallons per day. Calculated daily flow y gallons.
Nu uberefiheets ;Revi pate__ ' f
c-erm
Natu(e o[Rep ' or pp1 erations
G -1 (�ryywer w n a pI able)
l ECG
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 Boar of Health.
4 i ned k<, Date
Application Approved by Date
(ac - y
Application Disapproved for the following reasons
Permit No Date Issued
�3HECO NWEALr MASSACHUSETTS
G% /(/Q�r'- I ill--` ,MASSACHUSETTS
Certificate of lGmnpliance �y
THIS IS TO CER {{hat hp pn- ite Sewage Disposal System instal�{ed( ) r'{�./�yp augd/retplaced� ) on
'V � C[ Y � 1 , 1
SC I �C /P S it s G. < 6-v-�� >C r fare
at beetreogstructed in
dated
accor cf a th su7lons of Title 5 and the for Disposal System Construction Permit No.
/ / / / Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certifSetw sjt niltregonstrued as a guarantee that e s em will fwfction signed. This
Certificate explres„en a �` �'�iWi .t_.i '-�-Y�
JV
DATE (k ,y 1 ) Inspector
g:"1
THE CJMMONW ALTH OF MASSACHUSETTS %'J
li nFo i6-' I� II/A i /,64n ) .,
MASSACHUSETTS Fee
tN 6t3
r S. Disposal Srtem Construction Permit
ao m o a c < 1. �% /R -Lt--k,
.3 m m �ermsson is hereby g(a9ted to
S. 3 W struct( ) or repair(A)an On-site Sewage System located at
N C .H 'C 0.
C ..1 'C R, CS
1-4 , 6aa`� described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
L �a�❑iy an comply with Title 5 and the following local provisions or special conditiio-nns. / -7;y/
a > m construction t be com le d wt h�nIfwq%ars of the date below. %
(r,y / //// // Approved by ,G G
o N #3
FORM 1155 Rev.9[95 A M.SULK/CO-BOSTON.MA