HomeMy WebLinkAbout0154 COTUIT BAY DRIVE - Health 05�- 0� �
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LOCATI�N -��- SE AGE PERMIT NO.
VILLAGE
INST.Q LER'S NAME & ADDRESS
8U110ER OR OWNER
DA T E PERMIT ISSUED /72
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4 -T).,q (
... ......OF........ ... '.......................................
Appltrttttlau for Disposal Works TomitxurttnriT Vrrmi�
Application is hereby made for a Permit to Construct (./ror Repair ( ) an Individual Sewage Disposal
System at:
. ..................................... .. ..... .........:......_:(_1 - ..J® .......
Locationor Lot No
.®Iy ...
.......... . 5... .� ..................^........_
Owner ` ................................Address
Installer Address
UType of Building Size Lot....Y3..✓`-lo._a..Sq. feet
Dwelling—No. of Bedrooms............ ..........................Expansion Attic ( ) Garbage Grinder ( )
Pk Other—Type T e of Building ............... No. of ersons........................._.. Showers — Cafeteria
Pk YP g ----------•-- P ( ) ( )
Pa Other fixtures-----------_-_........................
w Design Flow.................5.,__.....___._..._..gallons per person per day. Total daily flow............ ..................gallons.
WSeptic Tank—Liquid capacityJ gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width_._..._...._ Total Length.................... Total leaching area....................sq. ft.
See a e Pit No....___. __ . Diameter._ _. ` epth below inlet.. ...... ....... Total leaching area..................sq. ft.
Pg
Z Other Distribution box ( ✓f Dosing tank ( ) �G ''-' G-a y-7`7
'-' Percolation Test Results Performed b ......... -
a y �..�.�.-----••--•-- --- --•--�---------------------- Date-----•--••--•------•-----------....----
,.a Test Pit No. 1._.Z_......minutes per inch Depth of Test Pit...� __...__.. Depth to ground water.l�l�+,tt _r'- _. b
(i, Test Pit No. 2.......2--..minutes per inch Depth of Test Pit.................... Depth to ground waterNN, S
Description of Soil. .--....... �f_`". ._. Q' a.. -.... ` � .G�.A K.- -
i ,
w
� X...................................................................................................-.-..-..-
V Nature of Repairs or Alterations-Answer when applicable...............................................................................................
-•--------------------------•------------------------------•------------......-•--------...........-----•--•---------------------------------------------------------------------------------•--•-•-••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L ITA!Z- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ued e board of health.
Signe .... > ` kly_ teZ� � ��7
Application Approved By........•... •.... --• ...... -------
Date
Application Disapproved for the following reasons:-------••-------------•--------------------------------------••••--••----•-•••..... --•.......................
--•-------•----------------------------------------------•-----------------•--•-•---••--•-
• Date
PermitNo................................................. Issued..... • v-7-----•---------------------------
Date
Fss
THE COMMONWEALTH OF MASSACHUSETTS
BOARD I-1 ALTH
OF..:.. ------------
A `
Appli-rattou faar Uiipnaa1 10ork.5 Tonstrnrtuan ramit
` fo a Permit to Construct r Repair an Individual Sewage Disposal>s heebY mader o
System at
i. Location re or Lot No
W #Z ............................................Address
................ -•------•--- ..............
Installer Address 1
Type of Building Size Lot....
' ._ *0__Sq. feet
U Dwelling—No. of Bedrooms.._... _Expansion Attic ( ) Garbage Grinder ( )
Other—T of Buildin No. of persons _______________________ Showers — Cafeteria
a yp, SIB-g ••---•-- ••--• P ( ) ( )
Otherfixture -•-- ••-•••-•----•---•---•••-•••-•- •-•-•-•-•--•-•-
W Design Flow_______ ______r ___._ gallons per person per day. Total daily flow__. --------
gallons.
WSeptic Tank—Liquid capacity gallons Length............... Width Diameter---__-_________ Depth................
x Disposal_Trench N _____ Wid h Total Length.................... Total leaching area....................sq. ft.
Seepage'Pit No. •----fw--------- Dlameter. Tlepth below inlet_ ___._ Total leachingarea____ sq. ft.
Z Other Distribution box ( Dosing tank ( )
v "
r
Percolation Test Resu s Performed b ......... :___. ._ Date____ __________
aTest.`'Pit No. I._ "`__- __minutes per inch Depth of Test Pit � _. Depth to ground water-.?A
"�.... _minutes per inch Depth 'of Test Pit_________________ Depth to ground water
G� Test :Pit No. 2____.__ ___. __.
�s �
Ot
Description of Sg�l !!- A __' -•_. ....................�ele ` . ......
x f / ' il?
U ------------ -- -.._ �. -- ---- _..... ........ _
W •------•------------'-------------------- --- --- - ---- -- ............. ..
UNature of Repairs or Alterations Answer when applicable-.__..__' .............................................
Agreement
The undersigned agrees,to .install the aforedescribe�d.Individual.Sewage Disposal System in accordance with
the provisions of`TITIL 5of the State,Sanitary Code The.undersigned further agrees not to place the system in .
e board of health
, i P e '.
� I.
operation until a Certificate of Compliance,liacgeri as-b` '- d ---_- ---- -.-............
-- �................
l'f ate
Application Approved;.BY `/• __. "' • - . .......
Date
Application Disapproved'f or the following reasons:. . .....--•-------------•---•-.----------------------•-------'----- ------==---- -•----------------
-•--••----•..........:..........••--------------•----=----•-----•-••--••-•-••--••-•-••-•-----•-•--•••-••--------••------•-----•--•-•----•--•__._.......
Date
Permit No.----- °F - Issued-----------•----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
...... .........OF:;:;.: . . °`....... ......... .....................
Cyr g ` r atr, oaf hunt fianrr
THI TO ERTIFY, That the thdividual Sewage Disposal System constructed (�+'"�"or Repaired ( )
by r .............
.::................. ----- -------- -------------
........___-_-_-----_-________---------------------------
&oftInstaller
at_.. ... ......... .. ••-•- •--,_.: " . -- . -..- -•• ---• - �' ...'.' .'.__..........--••------•-----
has been installed in'accordance with.the provisions of ,« The State Sanitary Code as c�escbe�i in the
Z application for Disposal Works Construction Permit � _________ _ _________ _________ 'da.ted. ..-�.. -------------------------------
THE
ISSUANCE°"CF'IHIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACT6kY:
DATE..._-------•................. .... ................. ....................... Inspector................ •---•------.......................................................
THE, COMMONWEALT..H,,OF mA!t!§ACHUSETTS
¢ , BOARD OF HEALTH
4.0
o ....OF... FEE .I .. .........
Permission ' ereby granted = --
to Constr ) o Re air ( nil Sewag &sal System
at No. ----
Street
as shown on the application for Disposal Works Construction Per o.___. Dated__ '"`"".....`_.............................
t .v
f Board of H altl}
DATE---- --- ......................... „ . �iA OA� ; .
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - -
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