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HomeMy WebLinkAbout0054 TROUT BROOK ROAD - Health 5 Trout Brook'Road - -- Cotuit VLA= 22 - 071 - � - - LOCATION SE ER NO. va,l L AG E 0"Z I A S T A LLER'S NAME S ADDRESS B U I L D E R OR OWNER DATE- P ErRMIT ISSUED - /7-- DAT E .COMPLIANCE ISSUED - 3 -7 �- �" �. w 0 gyp, t < v No.......... ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® E HEA OF......... .. ................................ Appliration for Uiipntial Vorkg Tnnitrnrtinn ramit Applicatii i�hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys at: w ' ......... .. ...... �5....--------••-•--•-••--••--•---- ....�1 Y.. ............ ocat'on-Address o Lot o. G l�zrS .............. ----- ---------------............ 2 i h ......................... ..._••••-- -- O ner Address e -----�:.......... - -?Tia�ss ► �o.�S.¢1c......• �S Installer Address 2 �' ✓ ----.S � Type of Building Size Lot____________________ q. feet U Dwelling—No. of Bedrooms.......%3..................................Expansion Attic ( ) Garbage Grinder 01b) Other—Type of Building :FM&',......... No. of persons......-�................ Showers (oL) — Cafeteria ( ) a' Other fixtures .-----------••. •.............. - W Design Flow..../40.X•3........................gallons per person per day. Total daily flow........3.3Q..........................gallons. WSeptic Tank—Liquid capacity.100 .gallons Length................ Width...._........... Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.......rf............. Diameter................. Depth below inlet................ Total leaching area...ft.1....sq. ft. Z Other Distribution box (0 Dosing t nk ) Percolation Test Results Performed by.._ i5 --... .... Date...A/,=,f `.. aTest Pit No. l----------------minutes per inch Depth of Test Pit........_........... Depth to gr6-und water_- _________-__..---.-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-___-__-___.--_-_._. --- - f------ ---- �1-= 1 . x W --------------- --------- ------------------------------------------------------------•--------------------------------------------------------------------------------------------. --- ------- UNature 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 iIT?:;:�. 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. Sign ....... ............................ • ...--•--------,............................................ -- -------------........- ` �� � Date ' Application Approved By........f-. --- . . ----•-------------------- ........--1--------7{�------ Date Application Disapproved for the following reasons------------------------------•------•-----------------------------------------_..-------•--••-•------------•-•-- -------------------------------------•--•-•-•-------------......••--------•------......--•-••-----------•-•••••••-------•--......------------......---•----•---......---------•-----•---•--••......----- / Date PermitNo......................................................... Issued-.-- 1 ='3 7 -----------•---•---- Date No.......... y :_ FE$....'�.�................. rTH`iZOMMONWEALTH OF MASSACHUSETTS AA t. RD EV 1 (1 _......OF........... I. Applira#ion for Uiipaaal Workfi T mAr #iun 'ramit Applicatii i hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at A au 5 IL ......... " ..... ----- -.--•--- --------------- oca on-Address j c ....-•--••a3 .. - --- ............... - ............................................... s G j 1 - ••• D ... ......5.............................................1. --- '1 Installer NIA Address UType of Building ` Size Lot............................Sq. feet Dwelling—ypNo. of Bedro a g R)ms........ ..........................:persons : .Expansion Attic ( ) Garbage Grinder ) '4 Other—T e of Building SU ....... No. of ersons__..... ................ Showers ($) — Cafeteria ( ) Other fixtures = ..... _ . _ W Design Flow_._�/Q_? 3........................gallons per person per day. Total daily flow....... �-<.:•....................gallons. WSeptic Tank—Liquid capacity1000.-gallons Length................ Width................ Diameter................ Depth............._.. x Disposal Trench—No.'.................... Width.............. Total Length....................Total leaching area....................sq. ft. Seepage Pit No......I------------- Diameter....'-._._:........ Depth below inlet...... :Total leaching area....ft.)....sq. ft. Z Other Distribution box (V� ... Dosing tank ) '_4 Percolation Test Results Performed ...........c' ............ Date... _.' . '._7 .'.... ,.� Test Pit No. I................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........................ Description of Soil.......�_..-�--�---....... - ---�'�-!%s?x_`1�:._.�--- - ------------ -r�---,�---- ----•--!-�---•• ---�-��-- �' x W -----------------------------------------------•--------------------------------------------------------------------- --------------------- ............................i.............................. UNature 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 T I TiE 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. Sign Date Application Approved BY .-_.� ` -''t. ._.1. 1�IG `.............."-•------ -- _ Date IIfp Application Disapproved for the following reasons-.........---------------"---"---------------------------------:--''------......;.,------------------"-"---- I .. „ham. ......................................................................................................................_.................---.._......_...._..__.............,...................__......... Date PermitNo......................................................... Issued................... ;. Date r THE COMMONWEALTH OF MASSACHUSETTS ot BOARD O HEALT Q'��r�f!'P...............OF............ .. , :. .. ..... ......... ......................... Tatif iratr of TompliFana T S,IS T00 CFyRTIFY, That the Individual Sewage Disposal System constructed (4ror Repaired ( ) by -��' ._ _.. ,€�._.............. . • •-"- -• "-"•-"" ""-"-"----• ........ fl, hasat been installed in accordance with the provisions o "' F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit N --- ___.__Jr.__-:Z................. -_-_-_--__.-__.._- THEISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH . O F.......... . ......................... d-o✓ ...... ... t�K ... + j +.Z..�.........:...........:. No....... .. ....•.... FEE...'` Permission reby granted_ A �°• V------ -k to Construc. ( or e air ( ) an/Individual ew ge °ispos U Street Is shown on the application for Disposal Works Construction P s. No,._ ..-f�� � Dated.-_�__�_ . ..... .._.... y ,- Board of Heal DATE............................"•••". FORM 1255 HOBBS & WARREN.; INC.. PUBLISHERS - - - T��:�l G►mil bQT A. . �• ►..10 G�.>tz�laf� C 21�tv�lG _ p' d t..2 : `at S � T7•a►L`( �t_ow _ 110 +� 3 s �3b G:P•17 , %�� � i ; x. ..e .H r4'MsM. � -Ic 'T ►C = 330,E lS0 %,• 49iS 6 PL7: t k t .Z ., • j l o0o sal+. °2 0 .° .r. SPoSAt PIT - USE loco 3A v PRoq t A u)PwA.LL , ��. x ► .0 60 CS:P D ti ' ToTA L. ► : PE1ZGDlQT1©tJ2�ttu 'O>z Ae4 9 as 3 Of � t• n •� C s. t `y9 ' 4, 1 A�. N WILUAPA "� ' Tf d .!0� r N Y E yr x I v No. 193s4 fy ,P k. 0 p Jl!>`!� NAL Tor,1'►+v,s .. .. .. .. 4''Pw� �uv•97 1 i LoBM �r�P� Il7bC I{h► a A p �..�. �[ sANn, W ITii t ; /a��.�'�2 :.d ! WA-5"EDLJ r f .r,` ; .. CEC�TtFt1rL7 PLC> F'L.40�1 } Ptzv�-t L� t.aGi�T t a Go -v I T . i �"aCAt.. 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