HomeMy WebLinkAbout0688 MAIN STREET (COTUIT) - Health (2)Vi CaDL4 `Yl1
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��_ PERMIT ISO.
LOCATION SEWAGE
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INSTA LLER'S NAME i ADDRESS
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BUILDER,I OR OWNER
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DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 13
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF... .... ................. .............................................
Appliratiou for Dispaii al Workii Totui rurtiuu Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
//� ^ Locate{[per/��Addr sjs C/ ,e or Lot No.
.............ate( . .S.A..I_!." ...'.Fv. Z.6.._ ..__.._...."___•_•_____._._.... ................-Js6._ �G--_-"'...........................................................
O ner , dress
a ....... e ..... , �` 5------•---------•--••---" ........ �-.,.�._t.�'ress...........................................
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___a w � .................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons-...____.___.____.__-______- Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------- ................
W Design Flow.........................................•__gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.... . ------ Diameter.................... Depth. below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..................................--------------------------------------- Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit______._........_... Depth to ground water___________-_-____---__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------------------------------
•-----------------------
•----. --------
•---•-----------------------•.....
--------------------
0 Description of Soil..............................................•-----••------------------------------•-------------------------------•------------------------------•-•-•----------------
x ,s&&d...........................................................................................................................................
c.,
W •-•------•-••---------------••-----•--••-------••--------------•...----•--•••....-•--•-----------------•--•--••----------••......--- • --- c
VNature o Repairs or Alterations—Answer when applicable_._l' ®-_____ _�_...... ..__CU..!!�...............
1,,��---1%..-� Z2-C ----------- =clr� .. 'f� ..:---------------------------------------------------------------------------------------
AgreerPfent:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in-accordance with
the provisions of LITL%, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has
L be e boar f-health.
Sign( ---- -- ---- ----------_-_-------
a e .... _cSi.
Application Approved By..... / '_. -------- � = .
v Date
Application Disapproved for the following reasons:-------------------------------------•-----------------------------------•----•---------------••----.........
....................•-••-----------•----•-•-----•-----------...--•---•....-----------------------......----
Date
PermitNo. . l.............`' ............... Issued.......................................................
�- Date
i
No..........
!....... FEa..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------..... OF..............1...::-. t... f u
-------------------------•....---•--...........•----
Appliration for Diipoaal Works Tonitrurtion jhrmit
Application is.hereby made for a Permit to Construct ( ) or Repair (r')J an Individual Sewage Disposal
System at:
-•..............---...---_..........:------................................................... .._...................._........-••-----------••----•---.......-----........-----.....----........
Location-Address or Lot No.
r ( � , f
Owner I r Address
•------•-------------- --------------••-•-•--•-------.........................--•--•-----•--••
Installer Address
d Type of Building Size Lot...........................Sq. feet
Dwelling—No. of Bedrooms........................-----•_.:'='--_--_--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures -------------------------------------•----------•----
W 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.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by---•-•--•--•••------------•....---•----•--•----•---...•................• Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •-•-•--------•••-------•-•--••-•-•••-•••--•-•••-.........•-----.....-•------------------------------.........................................................
0 Description of Soil........................................................................................................................................................................
v ............................••-•-••-••-....-•••-••'--------•-•-----------..........---.................---------•-------------------•------------------------•-•---.......--------•--------•-------•--•-
W
------------------------------------------------------------------------------------------•-------------------------------------------------------...-----------------------------...•--......--•-•-•-
V Nature of Repairs or Alterations—Answer when applica/ble.................................:../...__.... / f:........._:.
.........................
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of` TTT-Zj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.........................
� Date
ApplicationApproved By............ ................................................................................ --•---------.--I-Da-/ 1
' Date
Application Disapproved for the following reasons:................................................................................................................
.........---•-----••--•-•----•-----•-•-••-•-•-----------••------•---....••-•--••.....---•--•-••-••••--------•---------•.....•---••--•••-•---•-•---•-•-••---------•--•••-••----••-----••••-••--•--••-----
Date
PermitNo.................................!------------------• Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.... ................................ :.......................................
Trrtifirate of Tomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ')`
by------••--••--•--•-••••--•.. ----•.................•---...�..............------•-•--•--•---•-------..........---.....................------•--............._..•----•----..........-----•----••--
e Installer
at
'. ; r i
....... ...--•------------------------------------•-------------------•......----................••--
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION
pS TISF CTORY. /�
DATE = -�•--1� - 11----------------•-- Inspector... E`er _-__--•---- ----------•----------------------•-----•------•-•---
THE COMMONWEALTH OF MASSACHUSETTS
- BOARD OF HEALTH
.. l
No.......�............. FEE..........:............
Disposal Workii C�ono#ra ioat anti#
Permissionis hereby granted....................... /.----`--•--------------•'........................... .............................................................
to Construct ( ) or Repair ( . ) an Individual Sewage Disposal System
atNo................................................:......................................................../-----= ...
Street
as shown on the application for Disposal Works Construction Permit No........ . .... Dated...........
Board of Health
�
DATE = ............ .................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS