21 Title 5 Application/Permits 1998 No
THE COMMONWEALTH OF MASSACHUSETTS
4totrgA122A rO_ 2 . MASSACHUSETTS
PpyltrFIttAtt for plow:te tl bgMtrm eonstrurtioxt Permit
Application is hereby made for a Permit to Construct(X) or Repair( ) an On-site Sewage Disposal System at:
Location Address or Lot No. /COS}D
1 to ni OMPL.E. 6 ,06E
Caller's Name,Addr
44-is t 5
d Tel.NO.
Type of Building:
Dwelling No. of Bedrooms —
Other Type of Building
Other Fixtures p
Design Flow 9'
4 99 gallons per day. Calculated daily flow
Plan Date to-u X98 bS1 oSSts .
Revision Date
Title I%=ti'ie 0 9B-02 S
Owner's
— g
Address 1.V E5el.No.
ZO Nilr1P7ew/P I/
No rw -
Designer's Name.Ad ess and Tel.j. PF
It t6N Pan 6- S 627
290
Garbage Grinder(SC)
No. per Persons Showers( ) Cafeteria( )
Description of Soil
Lo,
gallons.
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
The undersigned agrees to ensure the construction and maintenance of the af
system in accordance with the provisions of Title 5 of the Environmental Code and not to
Certificate of Compliance h been is ued b this Board of Health.
Signed
Application Approved by
Application Disapproved for the following reasons
CA
enre
escribed on-site ewage disposal
place the system in operation until a
Date Issued
Permit No.
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
,MASSACHUSETTS
Certificate of klompliante
THIS IS TO CERTIFY. that the On-site Sewage Disposal System installed ( )or repaired/replaced( ) on
for
by has been constructed in
at dated the for
accordance with the provisions of Title Use of this system is conditioned nncompliance ew Permit
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
No ��
THE C
Inspector
MONWE LTH OF MASSACHUSETTS A-
, MASSACHUSETTS
structian Permit
Popsy(
Permission is hereby granted to
to construct( r repair( )an On
e 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 t be •mplet • within three en of the date below.
C1) Approved by
DATE
FORM OM.Re 1' Au.sU KIN Co.•BOSTON.MA