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Home My WebLink About0047 HARRISON ROAD - Health 4 HA rrisin�4 R i w m C�2n`�'v►11t El .S M E A KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.fiECYCLED INITIATIVE CONTENTIO% CeOW Fiber Sourcing POST-CONSUMER wwws4mg" org SM12W MADE IN USA GHORGANIZEDATWEAD.M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE. Appliration for Dispaa ai Works Tanstrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................ •'' •-- --------------------- ------------- ---------------•--------- ----------------•-------.---------------- a:on Address or Lot No. ............ .. . ... .._ ..............rdp.................... -------------------------- .. a O - er dre sAli: .. •' ............. �a .. .. ---- _:.- •-• '........ ............. _. ----•---.......... ...... I taller Address T Building Size Lot............................Sq. feet welling—No. of Bedrooms-------- ---------------------------------Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a4 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------------------ = aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---_--__--_-_-__-_____-- fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_--_-_-__-_-___-•-____-. 0 Description of Soil______________ ____ __ _ __----._ - .- 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia e has been�iJssued by the board of health. Signed - --- -- G Date Application Approved By -------------- 'l c^^�-",' Application Disapproved for the following reasons: ...................--------------------------------------------------------------............................................ --------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- --------------------- --------------------------------------- Date PermitNo. --------?�---------V ..................... Issued --------------...---- ----------------------------------.------- Date ASSESSOR'S MAP NO. PARCEL ,LOCATION SEWAGE PERMIT NO. VILLAGE �a ( a� INST All. ER'S NA ONE i ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED 3 - 5- _ 76 DATE COMPLIANCE 15SUED � _ � Mo � d o . rip -r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratioai for Elispwi al Works Toustrnr#ion Ilermit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at• %��... ...........-r�- �.. ..................... .....•-------------------•--•------•---••---------•------•--------.=------------..............._. Lo rt-Address or Lot No. ............ ..................... .... .... ..... ...........•.._. ..................0 ........................... .. _.. D ' aller Address ..__..S feet d` Type Building Size Lot.................... q. awelling—No. of Bed rooms...... ................................Expansion Attic ( ) Garbage Grinder ( ) p., Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QI 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........................ �14 Test Pit No. 2................minutes per inch Depth of Test Pit._-__-_-----__---•-- Depth to ground water........................ 0 Description of Soil.............. ---•------------------------------------------------------------------------------•-------------------------------------------•--•---- x V ----------- •---------------------------- ------------------------------ ------------------------------------------------------------------- ! --------------------------------- -•----------------•-•--------- �1 ....................................................................................................................................... . ..... 0 Nature of Repairs or Alterations—Answer when applicable_-__-_-..---1000_ � __ ____•________________--- ----------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia a has been issued by the board of health. Signed .._. `� r� .-- ------ .... Date Application Approved By ------------------- ,, -� .... - �/ ,.�. ......... 4 re Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------- -------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ -- -- ---- ........................... -------- ------------------------- Date Permit No. .......... ,a...------ .......................:. Issued -----------.............--------------------------------- - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of C autpliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by...............�............�-..-...--:'-- -� .--..--..-..................:..-....taller........-.-......- ..--.......................................... --..-..... -- ------_.--................. II Ins at �� ( , .��$r:.:v.QQ ......................................................- -----------.................................... 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. .......-� sr -- ------------- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------5... ... ....... .. �� ......................................... Inspector - ------- -------. ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE Disposal Works Tono#rnr#ion rrmit Permission is hereby granted-----------.\,,, n ems,- .,Q-.n..........•-•-••-•--••--......••--••-•-------•---•-••-••------•-......•••..........--•--• ,... ..... U to Construct ( ) or Repair ( -an I Cc vidual Sewage Disposal System atNo..............-- ---J4--------N- Street as shown on the application for Disposal Works Construction Permit No..X-f z_..... Dated.......................................... -�............................................... ........-•...................................•-•--............................ Bard of Health DATE. �./ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS