103A Septic Application & Permit 2001 I
• .
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
FEE
3 ±
tcation for !isposal $gstezu/Qlonstruction 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.
Owner's Name,Address and Tel.No. ��_ y 4 I
PA S h 2 n
Io3A C2cf/N
n,c R-iN�,�q�2.t
c kt R-t1=.S MA2€s 1
103 CROSS ,pR \ Rp (v.,L:san>
Installer's Name,Address,and Tel.No-
Designer's Name.Address and Tel-Nn
too RP An) Sfl 60D1
IrnOCTll MAGtNti') �Ph (4 q) 52l-S CI
135 So✓'1ltw...(]�r/+-+ 4ZD
errlso
10 nn4 yve. QLn
ILI FST LPoIdr,1 ANA
Wes;AM^c51Z1,,, ntAA 0 vc i'7
Type of Building:
Dwelling
Other
Design
Plan Date 02
B BOP
No. of Bedrooms £ e QJ1 BQ4"'0's C.arbegeGeind 1t )
Type of Building AQPCm�N No per Persons 6 Showers(L4 Cafeteria
Other Fixtures
Oe-Aew. 32L GPg
Flow I (O r lvAL gallons per day.
- Z3 -6 /
Title P . - oG e
Description of Soil 'Ati):-/ LANw-
lW C>,�D fJ�wN 330 GQD
Calculated daily flow gallons,
Number of sheets Revision Date
L Si(-I) — See Liots. C✓o- --o2,a p4)
D,SpcDAC p N
AL
A,CL
Nature of Repairs or Alterations(An
er when applicable) 0(50.4v). ate � $X151, Para i.M.ar--1 -I;car
AC S nAI\
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 y t Board o
Signed - j l-
<s-
Application Approved by Date
Application Disapproved for the following reasons
Date
Permit No Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
NCR-1)3/4 /),17i, MASSACHUSETTS
Certificate of Compliance
THIIS IS TO CERTIFY, that the On-site Sewage Disposal System installed ( ) or repaired replaced(>on
ir�r CI by for
C .. , jlt . J`:<-
at /GE 9 (-42(Se. (%11(I i has been constructed in
accordance with th provisions of Title 5 and the for Disposal System Construction Permit No ' / 3 dated
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 system will function as designed. This
Certificate expires on
DATE
Inspector
c� c
T E COMMONWEALTH OF MASSACHUSETTS
No. ! rrf lr , 'M '/ •7 t1MASSACHUSETTS
!flippant gs#(em Construction Permit
Permission is hereby granted to C
to construct( ) or repair(k)ap On site Sewage System located at
FEE
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/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.
i • - / Approved by
DATE
FORM 1255 Rev.S. M SULKIN CO.•BOSTON.MA