Cemetery Application & Permit 2001 No
031
THE COMMONWEALTH OF MASSACHUSETTS
_74467040±91424,--- MASSACHUSETTS
ppltcatto# for pizpusul gi9tEktt &instr'uction f ermtt
Application is hereby made for a Permit to Construct ( )or Repair( )an On-site Sewage Dispo al System at:
FEE
Location Address or.Lot Na_
ti7oru�ranieC..> /zp/A
Installers Name,Address,and lel.No.
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owner's Name.Address and Tel.No.
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Designer's Name,Address and Tel.No.
nit_
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building A7A'N7ENCE No per Persons Showers( ) Cafeteria(
Other Fixtures
Design Flow _ gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil N/A
CJ Garbage Grinder( )
Nature of Repairs or Alterations(Answer when applicable) S'LPT IC SY STGM Try />k re/Vey/iv)
AAT% (5dIL0'�,E IS To 13£ C orot..RCr(o ) ('I// S4 C J )C '%//mo of/f
_A SOO PP Sv sq• rv■
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 Board of Health.
Signed ,4/l% /4/ Date /02/ 1
Application Approved by / Date
Application Disapproved for the following reasons
Permit No Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
' r MASSACHUSETTS
Qlerfificnte of Qlmnplinnce
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( )or repaired/replaced( ) on
by for
at
has been constructed in
accordance with the provisions of Title 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 certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
No � L i� chi / �1/ -"' I �i7 MASSACHUSETTS Fu
!iSpDSat f Mtew (gout/pc-that 11J QTIW l'i
Permission is hereby granted to -� .ca z -T I)!
to construct( ) or repair(x)an O Sew4e System Igeatedat
ll`c
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 two years of the date below.
DATE y Approved by
FORM 1255 Per.9/95 AM.SULKN CO-BOSTON MA
P