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HomeMy WebLinkAbout0221 DONEGAL CIRCLE - Health 221 DONEGAL CIR Centerville A= 169 - 011 SMEADI KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED IM INITIATIVE CONTENT10% Certified Fiber Sourcing POST-CONSUMER www.sfiprogram.org SF1-01290 MADE IN USA GET ORGANIZED AT SMEAD.COM j / No.��`�' _ _ _ F>s... ..0............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ho__nepl_d�F................. Appliratinn for Disposal Works Toustrnrtinn 1hrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: E.�'1 �•4.��e Zt- '4 P.)...-an� --•-••-------------•--•--.........__..........••--•••-•-•--••-----.............-•----•--.......--- Location-Address or Lot No. Owner Address ------------------------------ ..-••------------•------......--------------•--......--- ...................................................... Installer Address UType of Building Size Lot_/&f8 .�0 ._....Sq. feet Dwelling—No. of Bedrooms.......3................................Expansion Attic ( ) Garbage Grinder ( ) a p-, Other—Type of Building ............ No. of persons............................ Showers Cafeteria ( ) 04 Other fixtures ------------------------------------•-----------------•-•••------•-••-...--•••••••••--•-••-••••••••--••-••-•-•••--•••-••--•••-••--•--.....----------• wDesign Flow.............. . .....................gallons per person per day. Total daily flow--------3P........................gallons. WSeptic Tank—Liquid capacity.10.40gallons Length__R Q__...._- Width....tT........ Diameter________•___-_ Depth.._V........ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... ............ Diameter.... ............. Depth below inlet.../............. Total leaching area..,/0Q.!?....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by....ANKOW.. ? #-.................................. Date_.#V ` .......... aTest Pit No. L. .......... per inch Depth of Test Pit___�.`1f°1���__ Depth to ground water..A,t84V.f'........ Gi, Test Pit No. 2................minutes per inch .-Depth of Test Pit.................... Depth to ground water........................ O Description of Soil.... �`__ Q�"� ittJe- ........... a� xM 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 iITU 5 of the State Sanitary Code—T e dersigned further agrees not to place the system in operation until a Certificate of Compliance has been i e board of health. •••••...........---•••••-•......................•------.................-•-• t ApplicationApproved By....... -•-••- ................ -•-•--•-••-•--•-----•-•-•--------------------------------- ---•--- 1_ .. .._.. Date Application Disapproved f h ollowing reasons------------------------------------------------------------------------- ---------------------------------•••••- ---------------------------•-- ---------------------------.•-- ..................................--------------------------------------------- Date PermitNo......................................................... Issued....................................................... `~� Date r No.4/...................... � t� FEs.l..G?_............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................... ------------....OF...................----......_.................. Appliration for Disposal Works Tnnstrurtinn rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...............•----....!...�..... .........-•---••-•---•-------....------------•-•---......------------...-------•-•-•---...--- Location- ddress ............................................ ... '1 .??.... t .................................... W f� Owner Address ----•-------------•-----...-•---•----...............-----••---•-...................__.......... ....................................... ...................................................... Installer Address // Q Type of Building Size Lot/_ _-P0 --------Sq. feet Dwelling—No. of Bedrooms----.- •-•••--•-•-------__-•._----____--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building �04.e............ No. of persons............................ Showers (it — Cafeteria ( ) dOther fixtures --------------------------•---••-•---•---------------••------------•------•-----•--•---._.._..----•- W Design Flow............. ......................gallons per person Qer day. Total daily flow..........................................._gallons. WSeptic Tank—Liquid*capacity .gallons Length.1............. Width... Diameter................ Depth....._.......... x Disposal Trench—No..................... Width.................... Total Length.........V----_.__. Total leaching area....................sq. ft. Seepage Pit No.....I............. Diameter---4......._..... Depth below inlet..4.............. Total leaching area.10'a.Q-----sq. ft. Z Other Distribution box ( ) Dosin tank ( ) aPercolation Test Results Performed by... _ROW__��'_'� _______________ Date- ' !� Test Pit No. 1..�._..........minutes per inch Depth of Test Pit-- __._.__ Depth to ground water�i3 ...._..._ V4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ _..__... .DDescription of Soil...!� -4091 ......•....... -----. 1'ZD r+ve > "� . - - - -....- -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 TITLL 5 of the State Sanitary Code— T e dersigned further agrees not to place the system in operation until a Certificate of Compliance has been iRsVe he board of health. /09 id .._-•..............•-----------...•-•-•-....•-- -• ! Application Approved By........ :............. ":e............................................................... Date Application Disapproved thief ollowing reasons-------------•----------•---...-----•-------------------------------------------•-----------•••-•-------•-.------ ............................... -----••----•-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................I.................OF..................................................................................... Trrtifiratr of Tomplianrr ' IS TO CERTIFY, That the Individual Sewage Disposal System constructed Ir ) or Repaired ( ) by.... - ...- --- -Installer at.. .� � �✓ .. ... �z _•---•- ---•••-•-•------•----------•------•-••-•------•-•••-•-•------------•••......••----..... f•--- has been installed in accordance with the provisions of TI Qj �;he State Sanitary Coe ribed in the application for Disposal Works Construction Permit No......................................... dated-_ !.'....._._........ ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................•--•---•-----........•----....... - -3-- ` 1. ----•--•-- Inspector............... -z..)....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rr � �• S No..�............�_ OF FEE........................ i�z* ks ntrnrtuan rrntit Permission is her y~granted. ...__ ..................................... t' t i individual ewa >S Q' S �Sy�ste n' to Construct - or,R al ( r a g at No.. {-�--•----• ----- Street as shown on the application for Disposal Works Construction Permit No............... _•I .......................................... ,. p=-- DATE. ._..... r:Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON TO OF BARNSTABLE r LOCATIONLhC-CL-CZEWAGE # VILLAGE C,--Af�cie--V {SCE ASSESSQ,�t,'S MAP & LOT INSTALLER'S NAME&PHONE NO. s t SEPTIC TANK CAPACITY O ' LEACHING FACILITY: (type) J (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: . ° COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by P�v Icon C-ci L- ~ 'P �. .> V% TO OF BARNSTABLE LOCATION , VJ EWAGE # VILLAGE 0�II� �/uV I ' ASSESSQZ'S MAP & LOT 114 INSTALLER'S NAME&PHONE NO. R—® ®� 1 nAa SEPTIC TANK CAPACITY Q' �- LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: " ® COMPLIANCE DATE: ® A II Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist_ on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1�pcl Olt LOT NO. : ADDRESS : Siev vywe OWNERS NMIE: 1/SY/�� cVq�,► V�. / \e4 fit/a►7 1 SEWAGE PERMIT N0. ;g < NEW: V REFAIR: DATE ISSUED:_ DATE INSTALLED:-- , a � INSTALLERS NAME 64, yJ l•J 4 INSTALLATION OF: © 14ATER TABLE :A•y,e FINAL INSPECTION BY:_ DRAWING OF INSTALLATION ON REVERSE SIDE : G � of PC). v a '4✓ �IsL if Lev.c3`:fo LL.E.1/• - -- C�EAIJeV-Al- r.fOTES zo 14 _ _ �—AA.L ELCIi 91NW xj Ae-Q MEAwt S�I�, Lf��OEI N 2 f.As a,.., 0 J`�C i ca►.�u. 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C.�/TEP/� _:�•__ �ea�� CcwTdat ��,���`K w,�,r� ,vvA,,a Ems' OF 3Eo•¢�"�,s «_ EXi37- 4PaT 64-641- haBERT PROPOSED SEWAGE PUPOSA,C SYSTEM • � f'E,C SA.n/5 i'E.(' ,;�E'O.E'OC M _. YJ�►d/. ,�47'-L�L,E.r/• � � 1. .. A <,- , �'f- E. � G4,1Z 6 :5 YEe JC e_j,:2,J o4cae PA Y "r _ � f'LG�t�17�� ;tvr No.1987. r+ � P . � /�T�► ' , . _- , .~' T 1- 4cW,/vC, � A . ` ?'�" J�'�; .� • - # 1-6JrCA,(IAIG i'E'OV/ACD fl( t,E� P120P05F-0 LEACH t"Ci PIT /' R a6,PPLIGAIIt'T': �I.1G1►.11EEfZ: D!`�p© + �.., �! ,J f ice, /; ,.• ;,a t' , '�.,`'� A%Zi?,CU F-&IG 1 N EEej M I 1 C• :•F V1 . FA.t.1 o V't V-I ------------ SCAM C �± `' F �y , f 1� t� C� �-^ �y `t �, �,- ti� As nro rED � �> f�7 f:.�, t���� � of>• vPG �•+�e APPLlC-A, ! i 0hi 901 J4 J ? li�i/ °; ' S1Ek�St � DRAWN my: C+++c© by: Ado rr= V"N No. '� �:�ntiMM1K't.RfA` mrn.rrrr,•r �,�.. -_ •�.- .