HomeMy WebLinkAbout0054 CRESTVIEW CIRCLE - Health 54 CRESTVIEW CIRCLE,CENTERVILLE
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UPC 12534
No.2� bsrco�+s`'`'
HASTINGS, MN
OC6�-6
NO.- -- 6 FEs..: L/..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
l Applirttttnn for Bhnp ml Wark,6 C9aanitrnrti in Prrmit
Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal
System at
o. tion-Ad re s or Lot No.
-- ----- ^----------------- --------------`---------------1---
W cr ..^ A d. Address
-.0............. ...•--•......._.• '- ............ ........'-----.............................
Installer Address 13,
Q Type of Building 3 Size Lot............................. Sq. feet
U Dwelling—No. of Bedrooms______ _______________________ __ _-._Expansion Attic ( ) Garbage Grinder ( )
u -- - No. of ersons---------------------------- Showers — Cafeteria
Other—Type of Building ____________________ p ( ) ( )
Other fixtures ------------------------------- - --
-- --------------------------------------- ------
W Design Flow---------------------------J_I_V........gallons per.p0' n per day. Total daily flow........: .........._.._...............gallons.
WSeptic Tank—Liquid capaeity_. 000gallons 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 ,k,�};) `/
a Percolation Test Results Performed b � � "�'..'� . �� ---- Date...-----. �— ��—� 7
Y -•-- ..
Test Pit No. I...a_.c .....minutes per inch Depth of Test Pit____________________ Depth to ground water-----!q d ...
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.........................- ---------------•........'----"-----'------•-•--•-----•-•.........................................................................
Ar
0 Description of Soil----- (,v�"
--- - ---------------------------------------------------------------
U -'-•------'---'-'-'----•--•-""'-------•------•------•----•---'---•-•-••---••--•----•---------'-'•---'---•-----------•--•--."'--'----'-•------'-------•----'-"'-'-•--•-•-•-•-•--.....""-'---....---
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 TITLE 5 of the State Enviro ental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Com lia ce as been issued by the bo of health.
r Signed ..... ... - - --------- ----------- ................. ........ ----�,^---------, -----�rce
Application.Approved By ......._. . ....U .. " __...- 0
------- --- .---------------- -__... ...............---..... .........- --- e-- - .....
Application Disapproved for the following reaso r: ................ ... .. ......... . ............... ...---------------
------------------------------------- _ - -
................ ..---------- -------------------- --------- - .../ .................
Permit No. ... ..��'.... .... Issued - ate
ace -
——————.————————
No. !�.......r... _- Fps.. .;
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r y TOWN OF BARNSTABLE
1 Appliration for Di ipv!ml Viirlw Tom3trnrttun ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
------.s-y.....
.................................
..)
y /� )I�oc lion-:1dd\ s (( ( or Lot No.
.................
_......... ...•.
Wr 4 / � -�� Address
•------ = --•••-. ............. ....... ...............................
Installer Address r Z' 3 o U
d Type of Building 3 Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms______________-----------------------------Expansion Attic ( ) Garbage Grinder ( )
• Showers —Other—Type of Building W _�� No. of persons--- ------------------------- p ( ) Cafeteria ( )
a' Other fixtures ------------------------------- - -
d _ ------------------------------------------------
Destgn Flow___________________________�.�.U-__---._gallons per•person per day. Total daily flow............................................gallons.
W /
WSeptic Tank—Liquld capacity... Length---------------- Width.....----------- Diameter----------.----- Depth--------------..
x Disposal Trench—No- -------------------- Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq.
�ft.
Z Other Distribution box ( ) Dosing tank.( -� T / Z' `1 - 7
aPercolation Test Results Performed by-.-------------------------------� ------------------..._.. Date............................
,a Test Pit No. I---d___-......minutes per inch Depth of Test Pit-------------------- Depth to ground water..... .' ...
�Z4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
---- ---------------------------------•-•-•-----..-.-•------------------------._--....--•------•-•--------•--------.-----
xDescription of Soil...... ............
U ---------------------------------------------------••--------------------------------------•-----...---------------------------------------------------------------------------------•-••-•-------•-•••.
W
----------------------------•---....-•----•-----------•-•-•--------------------•--...---•----------------------•--•----------••--------------------•••••---••--------••-•-•-•-----•--•-•--•---.........
Z.
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 TITLE 5 of the State Environ ental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp ii a ce -as been issued by the board of health. , f r //A;_
Si
ned .. ,. ;i`% Z..... ' - .. ....... ......`a' to
Application,Approved By . //r
Date
Application Disapproved for the following reaso CA � ---------------------------------------------- - te
---- --- -------------------------:---------------
--- -------- ---------------- -------- ---------- ........ / Da
Permit .((CC ----�- � Issued �f--�----------...f--------------------t ( i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Terlifirate of Compliance
THIS S TD CERTIFY That the�'n iu'du I Sewage Disposal System constructed ( v ) or Repaired ( )
by � .°C-._ :- ---- .------------- - - - -- -------.------------_----------- ------------------
ler
a[ --------- ---------�. ---...--------.....--- ---------------- - ---------.....-----------------------------------------------
has been installed in accordance with the provisions of TITLE 5 •f The State Environmental 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 SATISFACTORY.
DATE / ... - -- .- .. -- -- -- -------------- ---------- Inspector ' s/------ --------------x---------------- ,
9
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f TOWN OF BARNSTABLE
Vermit
No........ FEE........................
t t
�is�rn �t1 nrk� Cnnntrrti�n
Permissioniy hereby granted.......Q-........ --•------------------------------------•---•-----------------------------••-----...........
to Construct v) or Repair ( ) an Individual Sewage Disposal-System
. . ----------------- .........................
as shown on the application for Disposal Works Construction Permit Street
w!-.`l_ Dated----- -6.2...........
Board oHealth
DATE------...... ........................................
FORM 36508 HOBBS♦!t WARREN.INC.,PUBLISHERS
TOWN OF BAR,NS�Ty_ABLE V
LOCATION = % JT // U1 �� SEWAGE # r �
VII.LAGE 1k1 SSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. Y22 ®-
SEPTIC TANK CAPACITY AMW
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: f'' COMPLIANCE DATE: + "
Separation Distance Between the: ,� y
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on st a or n 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of IRChing facility) / Feet
it
Furnished by
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2
1 y
Z 32.6 5-
TOWN OF BARNSTABLE � t
LOCATION = G2iS7'r_i1R1,t7__Z? _ SEWAGE # /
VILLAGE Cf�'�1T�1 i�.� SESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �DUU
LEACHING FACILITY: (type) i T (size) 17�
NO.OF BEDROOMS 3
n
BUILDER OR OWNER q
PERMITDATE: .! COMPLIANCE DATE: * '
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
r
Private Water Supply Well and Leaching Facility (If any wells exist
on sire—o7vidV67200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of kaching facility) Feet
Furnished by
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TOTAL DAI�Y: j� :�3�So 1,a
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