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HomeMy WebLinkAbout0205 JAMES OTIS ROAD - Health oS -'aMes aTIJ ra C�eAll v;P18 170-- Zo7 /// S M E A D KEEPING YOU ORGANIZED No. 12534 2-153LOR SIAMM LE MIN.RECY=D jGX INIilA71VE CONTENT 10° CordfieaFibersoureinp POST-CONSUMER wwwApmaramorp maim MADE W USA GF-T ARGANIM AT SMEAA.GO1u t No.. xkln- � Fxs 7U............. THE COMMONWEALTH OF MASSACHUSETTS BOA R® 1-I EA .T - ...OF...... jia� ................ .............. AVV irFation for Bi-gpvii al Warks Tonotrnrtinn Fermi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal .......em at: . ......-••......... ........ .-�... -•------ -------- ------------------....----- �.� Loc n-Address or o. .. --------•--•---- . er .Address Installer Address Type of Building Size Lot_. "�?�_,Q' _Sq. feet. U Dwelling—No. of Bedrooms_____________-3__.•................._._.._.Expansion Attic ( �b Garbage Grinder ( �/O aOther—Type of Building ............................ No. of persons.................._......... Showers ( ) — Cafeteria ( ) Q' Other xtures -----------------------••-----•. W Design Flow..........._IIF� .`�.�.................gallons per person per day. Total daily flow---------- .............gallons. rx Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W 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........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.--_---_----___. -----. Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ....-•••--•---------•--•------•----------------------------•----•--...._..------•-----.......-----....-------------•--------•-•----------......._..---------- 0 Description of Soil..................................... x U W x -•--------------------------••----•...•----•--------•-------...--•-•----•---------------••-•-----------•------••------•----•----•----•-•--•-------•---------••------•-•-------•-----------•••......••... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------•--------------------------------------------------•--------------------------------•--...----------•-------------------------------------------------------•-----••-•••----•--•-------......._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Dis osal System in accordance with the provisions of iIT E 5 of the State Sanitary Code— The undersigned furtl: agrees not to place the system in operation until/!/ ifi�f mpliance has been i d y the bo of he g Si ned_. . --- - -------------- Date Application Approved BY =follo �� ------•--------------------------------- --------------- - ,6 Date I Application Disapproved for thg reasons--------------------------------------------------------•------------------------.....................•........ •--------••---•-•••--••----•-----------•--•--------...-•--•-------------------••--•------•-•-••---------•---..............--------•-•--••----•----------------••--••-•--------•-------•-•-----•-•••.=-. Date r. PermitNo.---..... -----9.2..G........... Issued----------------------------------------- -------•---- Date No..- -6---G Z Ib THE COMMONWEALTH OF MASSACHUSETTS B®A RD,,QE H EA y , =-- ---.OF....................t '............................................................... `�... Appliration for Disposal Works Tonstrnrtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual' Sewage Disposal System at v ..--.... ... ..... '........................ ............"............................... T_ ........ . -----.. ................... '+ Lo ion Address �/' ` P No. .. C Y. r ....... ........ ...................... a Address Type of Building Installer Address Expansion Attic ,� f Size Lot_°'' ?, ----_------?_.•Sq. feet Dwelling No. of Bedrooms..............:. p ( Garbage Grinder Other—Type of Building No. of persons............................ Showers — a YP g -•-------------------------• P ( ) Cafeteria ( ) 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------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........................ a •-••••-•--••-----------------•------•••---------....--•---------•--------•------•--•••••......--•---..................................----------- .......••-- 0 Description of Soil.......................................................................................................................................................--------------•- x W ----------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable............................................................................................... •• ••••-•-•-•••-••••-•-•--•-••-•••-••--------•-•-••--••-•-•-••---•-------------•-- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Di posal System in accordance with t'1 T L.1--�-� the provisions of l _�-.;: ;of the State Sanitary Code—The undersigned furt'r. r agrees not to pl ce the system in operation until a Certinca of mpliance has been isi ued,by the boaTdoi health. rg tgned �_�.� `---- - -- ---------------------------- A ` Application Approved By..�1�.G{� l N V �. _g.L ••.... • -----••••••--••...................•......•. ........................................ Applieation Disapproved for the f ollo g reasons_ ___________________________ --.-----••----•................................. Date.............. --•---------••-•••-•---------•-••----••••••----••-----•--•-•-••----•------•-----•••-•---••-•-••-•---------------•-------•------•-------•--•••----••-•-••-•-----•--•-----•---•-•-----••••----•--...•-•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................I........OF..................................................................................... Trrtif irtttr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( } by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at---------------_---------------------•---------------•------------•---------------------------------•--•-•----•-----------•------------•-------- ---------•---•--•--•----------------------------- has been installed in-accordance with the provisions of TiTIE j of The State Sanitary Code as described in the application for Disposal'Works Construction Permit No.__ _�... ._24?�............... dated...... -.__-____-_._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT ifHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ...........................................OF..................................................................................... ................... FEE........................ Dispooa orko �onir ion Vrrmit Permissio hereby granted !�^ : to Construct ( or�Repair ( ) an Individual Sewage DisposalSystem at No_" --1.S.....-•-- ctti....................... ' Street as shown on the application for Disposal Works Construction Perm•t No.__.�__�� Dat d.._.�..._.......__.....�............. ��, 4, •-•--•-•-------•••--•-�•---- kai DATE.................... _��---��--�.............................. Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - L7. 1 L ci t71 s� �► .. - <17 �� -ro 77 _ � , t `3 �:o� pad. _ . �►o�5 4IL 120 �`rlt Z_MJl�1,.CDK L 1�55 , _ POSH, OF �,- PfT SULLIVA " BARD PJo. 2973 y'' q,9? P=32 IONAjL :! r _ ( ' 44 t ,, r vvL� t ! ►. A. °' �� GAL C TAN ': L�EIZTl i-t Et7 17 ' T PL W o K/-= Qt` 7. - ,t . ' ,zovos�.b LtJT � oxl C�WN 14 b. 11 T W N ' -T t 5 Nam' zv EYE 11 --1?• L �1 I pL l N :ul Lk MASS+ I _ ___- . _ _ ._. 1' 1 i ra 7 V)I$ �1�,tom: l 5 NOT 4�N L �1 TO C-5-f LI f. -A L�O-T ,-9-AI. •ANF.Nt GUIGE LINE .,.-..10564.1` o TOWN OF BARNSTABLE LOCATION I 5- `�i6AfF=-'S� 0-r1 SEWAGE VILLAGE C&Jrek U lIle ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.']'?. (,1UIC' Chi y �� fa <341 ASEPTIC TANK CAPACITY ,© % 1 �.EACHING FACILITYAtype) � (size) 6 "toll O NO. OF BEDROOMS—a PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER4G,d/lI DATE PERMIT ISSUED: 7 ` DATE COMPLIANCE ISSUED: S FS VARIANCE GRANTED: Yes No ./ 1,01", sJ f3ACK Y-b