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Home My WebLink About0144 COTTONWOOD LANE - Health �1 Culron Woad C 6r\l e (v i 110- Zsz - Iti6 S M E A D No.2453LY UPC 12934 ssmead.com • Made In USA 3 0 S FOS RY E INITIATIVE Corded Fiber Sourcing www.cbrowums I r � � � � LOCA ION SEWAGE PERMIT NO. VILLAGE INS A LLER'S NAME a AD RESS CA h O , UILDE R OR OWNER RS ' DATE PERMIT ISSUED ODAT E COMPLIANCE ISSUED �- L -F�.��T 5 � � ', � a o ��, -_, .� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ........_ ----------------OF.....-eLJ�7:/ /r %� ......._......... ApplirFation for Disp as al Works Tumitrurtuan 1hrutit Application is hereby made for a Permit to Construct (V") or Repair ( ) an Individual Sewage Disposal System at 4 �r ....---- -- -� _[mot C.� .... ...- -------- ...�c-... ` — K...--- CVdress �►A ........._ t No O dress 19 Installer Address n �y G U Type of Building Size Lotlal,! -----�.Sq. feet Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) I' Other fixtures ---------------------------------•---------•---------- W Design Flow............... -�----------_-•____gallons per person per da/. Total d ' .....g_50.................gallons. WSeptic Tank—Liquid capacity/M49..gallons Length/Q__�,6.. Widt ............... Depth................ x Disposal Trench—N ..._...._ ..._. Width_................ Total Length... . �....._ Tota `f g area------------------sq. ft. Seepage Pit No....... ............ Diameter...�,�...r.._CQ. . Depth below inlet .� - 1 1 m g area.j�.._��_.��.__.sq. ft. Z Other Distribution box (VT Dosing tank ( ) " SSMAN a Percolation Test Results Performed by-_. N0' �2705- a //® v / ------ ----�- ,� Test Pit No. I._._......minutes per inch Depth of Test Pi ti _. 9� 'Pf� tilgl nd wate ._ �. fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit1Q.... ._ . �' ound water...° 0 ..'........... ....•--.......------......------......-----•..•......t................ •--••---........---..._.............................-- Description of Soil /2.'._----V(,r.�o .d� f ........ - • ' .. -----••--------------•-------------••••--------••---•-----------•--•-----••-•-------•-------•-•------•-•---•-----•---------•-•----•-------•--------•-------•-------------••---------...---•--.....------ V Nature of Repairs or Alterations—Answer when applicable............................................................................................... * -------------------------------------------------------------------------------------------------•-----•-----••---------•------------------•------------••------------•-.............................. Agr ent: T e undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with e visi lis o '11RU of the State Sanitary Code—The undersigned further agrees not to place the system in o do i tifi of Compliance has be sued by the board of eal i r a 'on Approved ....... . --•----••---------••.............•-------••----.•...:.............................. Date Application Disapprove r e lowing reasons______________________ ............................ ......-------- •--•-•-•--•---•-•...........................•-----•------•----------•-----------------------•---...--------------....---•--------•-•-----------------------------••------•-------.•--------------------- Date PermitNo......................................................... Issued_....................................................... Date Y t6"M::----------- --.. FEa.............................. ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---•- ----------------------------------OF...-.......-.........-...-.--........... App iration for Uiopniitt1 Work.5 Tonstrnrtiun thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_................................................................................ ....................................................---------------------------------------------- Location-Address or Lot No. ......................_........................--.... ....-------•----.......................... ......................•-•---..................-------•------.....•----............................ Ownerr Address W Installer Address Type of Building Size Lot............................Sq. feet I—I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons..........-----.---..--...-- Showers ( ) — Cafeteria ' ( ) Otherfixtures ............... .....•-•--......---•--•--•••-•------.....••--••-•-••-•------•-----•-----•--•-•----••-•-•-•-•-••-•••••-----------•---••--•----•_•----- RW Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.....--.....gallons Length---------------- Width................ Diameter..........--.... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.--..........--..--. Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b .................................:................... Date........................................ .;� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......------.--.....--. t%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......---............... M ...••--•--•------------------••••-••••-.....--•--••---•••••---•-----........•••...........•-•--.--•--...----------•-•--------•-.................. .----- --••- 0 Description of Soil.................................................................................. W --------------------------------------------------------------------------------•------------------------•----------•----------------------------------------------------------------- ................ U Nature of Repairs or Alterations—Answer when applicable........................................................................................._...... ------------------------------------------------------------------------------------------------------------------------- 1`. Agreement: The undersigned agrees to install the aforedescribe ,-Indivldtiai Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code #.Tli`6''0ndersigned further agrees not to place the system in operation until a Certificate of Compliance has begin 4i�, by the board of health. rollowSing �..... .:- :- ....... ------------------------------Application Approved .............................•----------•---.............-•---•--• -•----••-------------••----•......--•-- Date Application Disapprov oreasons: ....................... .........-•---------------------------------------•----------...-•--------------------.............------•----: --•----••-••-•-•-••-•-•---•-----•-•------•---•-•-•-•-----•-•......•-•••--•--•--•-- Date PermitNo.......................•---------••--•---•-------------. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 41E30AD OF HEALTH ..........................................OF.................................................................................... Trrfifirate of Tantlrfianrie THZ, 9 IS TO CERTIFY, That the ividua ewa Disposal S- tem constructed ( )o or ( ) " bY------,j,� "----....• ... .................... -------------------------------------------------------------------------- at........ ----- ------•- has been installed in accordance wi the provisions of TIT /5.of*lpState Sanitary Code as described in the application for Disposal W ks nstruction Permit No......................................... dated------------.................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. /� DATE................................. `1.� . ... Inspector.........14.:./��.......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.•••--•••................ FEE........................ Permissionis hereby granted.......................................... ------------------------ •....------.......... --------..............----...... to Construct ( ) or,Repair ( ) an Individual is� Sy �. atNo.........................................................................•-----••----•-••••--•.••----------------•---------•----•-••--••-••-•---------•••-••----•••- Street _ as shown on the application for Disposal Works Construction Permit-No...--............ ted.......................................... ....................... --=--------------------------------------------------------..._......._ DATE. Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON VITC-i4- ,0.t..�._ �.-t J 05 p, Mt 1,Q t M v� 41� f,*>'f mac rr �___, Al-L_ Pl O ( � � it 1 � tr�3 Ti!J At�.3 t� 1 i,,.S TW{� twSfi� I ` ` J _ 15E CA S r l'gip i,,3 Cg-- 15C.44 1S ID U►,A�_' .. 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