30 Application & Permit 1998 •
To
THE COMMONWEALTH OF MASSACHUSETTS
Yip MASSACHUSETTS
FEE
�pplication far !ispasal !ystem Construction Permit
Application is hereby made for a Permit to Construct ( ) or Repair( )an On-site Sewage Disposal System at:
I oeaion Address or l of No 1
a� u '� �' rAX , L
rez CE
Owner s Name,Aress and Ti.5 No.
«!d`e d _1 F PO f+' .:.yarnol4Vrc L
Dqs6 Name�;ryaa err�g rti.Na (V I' ,nyLT/: '' l)'
tm an name.Address and ncik9, q
i r t ''S'''lL (� tr)eCGCG4
—I cv Lo
Type of Building:
Dwelling
Other
No. of Bedrooms
Type of Building No per Persons Showers( ) Cafeteria( )
Other Fijtures
Garbage Grinder(')
Design Flow gallons per day.
Plan Date
Title
Calculat i daily flow — gallons.
Number of sheets Revision Date
Description of Soil
Jr
of
Nature of Repairs or'Alterations(Answer when applicable)
Date last inspected'
Agreement:
The undersigned agrees
system in accordance with the
Certificate of Complianceifns e
Signed (/w
to ensure theconstruction avd maintenance of the aforedescribed on-site sewage disposal
V�'isions of Title 5 of the Environmental Code and not to place the system in operation until a
jl en issued by Aitfs Boygi a[ fh. r.
Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No Date Issued
PA- Z-M----. 2 ) / D---
THE COMMONWEALTH OF MASSACHUSETTS
.4' -lc/'./tTvi,; MASSACHUSETTS
Certificate of Compliance
<THISJS 7'9 CERTIFY, tJat the On-site Sewage Disposal System instaileQS ) of ropatredlreplace jl'Jron
Y � .
for ,.
at , . - heed)constructed in
accordanpe with the rovisions of Tile 5 and the for Disposal System Construction Permit No dated
/ Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this cert'tficatg*all,ttett)rercotsirued as a guarantee that the system will function as designed�This
Certificate expires on // _. rJ A ; �+.� -'7/
P 6= 6y / r'
DATE 1 Inspector
No.
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
PispoSUI $ ' tem (donstrurtion 1ermit
Permission is hereby granted to
CO construct( ) or repair(L)an On-site Sewage System located at
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 oust be completed within two years of the date below.
DATE Approved by
FORM 1255 Rev 3,9 5 AM.SOLYIN CO.•BOSTON.MA