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HomeMy WebLinkAbout0060 HORSESHOE LANE - Health Ce nf-trvi f j� Zo7 ©77 /// S M E A KEEPING YOU ORGANIZED No. 12534 2-153LOR ONSUSTAINABLEFO Y MIN.RECYCLEDTIATIVE CONTENTIO% CeaedFiberSourcing pOST.CONSUMER wwwsfipro0ru w0 SR OWD MADE W USA GET ORGANIZED AT$SAD COY 1 - No....7 Fns..... .® - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applira#ion for Disposal Works Ton131rndiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System at: .............. ......... ...... .............................................. -- .....--------.-.-. -----.-- Location-Address or Lot No. i ......................--........................................................................ ..........--...................................................................................... Ow}'er Address -----------------------------------------------------------------------------------•••••-•--••--- Installer Address d Type of Building Size Lot............................Sq. feet Dwelling k!f No. of Bedrooms..... -.------.-_----------------Expansion Attic ( ) Garbage Grinder ( ) pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------- -- ----------------------------------------•----........-------•----•--------•----------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/,Sb ggallbns 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 ( ) a --------------------- Percolation Test Results Performed by........................................................................... Date................... Test Pit No. I................minutes per inch Depth of Test Pit.--.--.............. Depth to ground water...-.-.----.----.-.....- 4, Test Pit No. 2................minutes per inch Depth of Test Pit.....--............. Depth to ground water........................ a ---....-.................................................................................................................................................... 0 Description of Soil...............................................................................-----------------------------------------------------------------••---•---••-•-•--.-•--- U ----------•--•--------••--•-----•---•-----••---•------------•------------------------•---•-•----...................................................................................................... ----••---------------------------------------------------------------------- ........................................ ---------------------- U Nature of Repairs or Alterations—Answer w applicable-.---------. e,---'fit'fry f J C_.-- w.. ...._..6/;,i?�1�o _A ..........................................................................._... ...... ...........---...---..................................................................------....-. 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 CompE.. H n issued b board of health. v Signed . G�� ---- ----------- -- ..Dne ApplicationApproved By --- -------------------------------------------------------------------- ---------------------------------------- ' Date Application Disapproved for the following reasons- -------------------- - .................................-------------------------.............................................. -------- -------------------- --------'.-..-=-----------------.-----------------. ------.--------------------------------------------------------------------------------------------- .......:............. Date PermitNo- -------------------------------------------------------------- Issued --------------------------------...--------------....--------. .-- Dam it .r A x• FimB t THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Uhipoii al Works Tomitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (,i_�aan Individual Sewage Disposal System at: 60 Location-Address or Lot No. z ......................—.......................................................................... a Ow�er Address �cLN •--•-•------------Installer Address Type of Building Size Lot____________________________Sq. feet a Dwelling-Z.No. of Bedrooms___.. ____________________________YExpansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) POther fixtures -------•-----------------------------------------------•••----------•----••••••-•'•••-----•••--•--•••••••-•-•-•-••••--'-•------•-•••-........._••. W Design Flow............................................gallons per person per day. Total daily flow................................... _...___gallons. WSeptic Tank—Liquid capacity,/5' 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........................................ a Test•Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_________-.__-__---_-_-- G%, Test Pit . 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ---------------------------------------------------------------------------------------•---------_•--•----------------------------•-----•------•-•----------- Descriptionof Soil........................................................................................................... U ----•-•---•••-----••--•-------•-•••••••-------------•-••••••••••••-•••••--------•--•-••••......•--•-••-•--•-•--•-•--•-•••••••-•------------•••---...................................................... W ' x Nature of Repairs or Alterations—Answer wh a licable--._________ �1rr f-zs_ To 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 issued by�the board of health. Signed --- -- ............................. -------------------. . .. -- 1-. ....---...... / .- Iratew . Application Approved BY _.....- ----- ---- „z x ... ---------------------------------------- Date Application Disapproved for the following reasons- -- - ------------- ----------------- -------------------------------------- ------ -- ----------------- ------ -- Date PermitNo- -------------------------------------------------------------------- Issued ............................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD,OF HEALTH ,r TOWN OF BARNSTABLE ` (fertif ratr of (110'Mpli are THIS IS TO CERTIFY, That the lnd�vidual Sewage Disposal System constructed ( ) or Repaired Y i - Installer at --------------6-n......... �- ------------- -------------------------------------------------------- ------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code a escribed 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...........P-.1--5--~"!..1J-------------................................................. -------------------- -- ----------------... Inspector .. ,.....; -w .,-------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _r TOWN OF BARNSTABLE Disposal Workii Tono#r ilan rrmit r = - - Permission is hereby granted.............. : :. i E............................................. i to Construct (- ) or Repair ( !an Individual Sewage Dis asal S, stem , Street as shown on the application for Disposal Works Construction Permit No..__,7���Dated.......................................... \N ......---------------------------------------------------•- DATE--------��''r.- �'���....------.. ...•. Board of Health 0 FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE Q LOCATION D /%® fcsh`e �i9�,r SEWAGE # VILLAGE �� c-r 4 ASSESSOR'S MAP & LOT o24 INSTALLER'S NAME 6i PHONE NO.SEPTIC TANK TANK CAPACIT 40 LEACHING FACILITYAtype) �// , V,-4 cl.;' (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: J r � DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Q I �. 0t 6 . lot 30 Lc �ly- .gym 'a 10 ���/�