HomeMy WebLinkAbout1124 OLD STAGE ROAD - Health t)
5 M E A
KEEPING YOU ORGANIZED
No. 12534
2-153LOR
0 SUSTAINABLE
FORESTRY MIN.RECYCLED
INITIATIVE CONTENT10%
Certified Fiber Sourcing pOSTCONSUMER
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MADEWUSA
GET ORGANIZED AT SMEAR COO
TOWN OF BARNSTABLE
LOCA'I I iON SEWAGE # F,3-` -5
VILLAGE ASSESSOR'S MAP & LOT '7 '-
INSTALLER'S NAME & PHONE NO. ,To/)r A 4,46. 9/?S
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATE
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED:.'Yes No
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APPROM THE COMMONWEALTH OF MASS ACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
° ,� 1trtt ii t for Di ipwial rlt C�ugt�trurtiun Permit
Application is hereby made for a Permit to C�onstru� ( , 0t' repair ( ) an Individual Sewage Disposal
System at:- p // i p
..--�•1 .''� Y•� J-- ' .......Cex �,(�i1L.2.1�(
ND1/ }�� Locatinndn` 1 ......................... ..... '�C t.....0A....... .1.! � -Lot N
- 1;Y.....
. PY
O�cncr ddress
44
Installer Address
S feet
Q Type of Building 1� p Size Lot............................ q.
U Dwelling—No. of Bedrooms._.._✓......1 fA...................... Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ___________________--___-- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures _______________________________ _ _
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity 11000galIons Length________________ Width-...___________- Diameter................ Depth................
Disposal Trench-- No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No................... Iameter___.._..._........_. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( .. Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -------------------------------------------------------------------------------------•----•------------•---------------
•.................
.............
••••--
0 Description of Soil........................................................................................................................................................................
V ..................... •••.........•-----••.............••--••---.........--••••.....------•-••--•••--------...--•--••--•-•------•------•-•••-•••-------•------•-•-•-•-•---.............................._
W
-----------------••--------.._......----- ----••-----------.....--------•-- ........................................ ...
UNature of Repairs or A erations—Answer when applicable__.._.. � __ ___.�...._�X�..................................................
-4z s4711/ /av" -e,cti
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 Compiia c h s been issued by the board of health.
- Signed ......: .
2— 3
Date
Application Approved By ................. ....... ....... °.. ..........:................................................... ....//.!7... .^...��
Date
Application Disapproved for the following reasons: ................... ............-- . ...................................................... -- -- . . .
---.................--....................:...........--------.................--.......................... .............. Dace...........------
Permit No. ......../......3.....'.........�1..�� ......... Issued
` Date
l�
^"•"^`1''''°'C7tiT�'�"w�n-l.r.. -v��.%+'uw.-.•.+,✓-+:..r;_,l.d.Y-..��-�-'",,,r,^-•-+.a...+a�'�-�r....trvti�r..�....+-+U•`f�_``'v-vs`�-r• v�...�.....,!".r-"�►e.�....v.-.
THE COMMONWEALTH OF MASSACHUSETTS
t. BOARD OF HEALTH 1 ti
Ile y .,, �;-,2 _ s 3 TOWN OF BARNSTABLE
t
pp �oo hratiou for Ui�� nl Works Tomitrurtion rrm't -
� • { 1l.� � ��
Application is hereby made for a Permit to Construcf'(�) or Kepatr ( ) an Individual Sewage Disposal
System at:
11
H...'...-- ��� �.s� e�!r�i��� !� `. ---off- ST ----RD--..-----
Location :�ddress r Lot No-
W owner Address
^•�^,'+� �� 1 ........................................................... __w�_la[�? `�;.._....�lil la�ST /My./J.�......._..
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms-----5_____.�&_______________----_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
d Other fixtures . ..........
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitvJPOO..galIons Length________________ Width................ Diameter---------------- Depth................
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Iameter.................... 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........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 -----------------------------------•-----•-------------------------•------._.....--•-•-•--•--...._.......--•----•-•---•-----......._.._.........__-........_.
ODescription of Soil........................................................................................................................................................................
U ---- ..................................................
W
......................................................--------------------
U Nature of Repairs or Alterations—Answer when applicable..._-- 1'I..................................................
---- •-....-•---------••-•----•-_... .)_
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 h s been issued by the board of health.
Signed......` - "..:............................................................... ....../
Dare
Application Approved B .............................................................. p
PP PP Y ..._............ ... ..... ....... _�.. t 1/..-. ..... 2
Application Disapproved for the following reasons: ............. ................................................. .. ..... .........................................
....................... ................................... . . .. ...--.........__................ ........ ...............................-- ..... ......--... ---------- ...........................
q Dale
Permit No. --------��. 3-----..------- 1 �} Issued
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TlO��WN OF BARNSTABLE
ertificate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ........................ .-----------!! >.]0��.---------..---------------_- --------- --- ---...___---..---------------------------- ------ ................................-
1—alle[
at ...................... ........0....I.CQ..........5--fa- --CV ...............................................................
has been installed in accordance with the provisions jf TITLE 5y f The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _/ 3. �j 3 - dated ...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. °�
__........._............. - .....--....F'.._ _ant!c.l..- )....-.. Inspector.......?. /1!1> ,._....:-.:.--0+....... . 1 ...........'-
DATE
----------------_.---------- --------- -------,------- ----_---_,---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�y q TOWN OF BARNSTABLE
Disposal orko Tonotrudion "rrmit
Permission is hereby granted--------------�'4 �n V-------------------------------------------------------------------------------
to Construct ) or Repair (e) an Ik&lvidual Sewage Disposal System
-.)Ly—------------1
at No-_-•-•-_-�/.. -94 . •��. it'- .......... o.. %�. .. .� �� .._..
f street e�
as shown on the application for Disposal Works Construction Permit Not::_5�f� Dated...........................................
...........................• ------------------------------------------------------
�� - ! / Board of Health
DATE................ _ .-.l.__ ..---------••-•--•-•--------••
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS '
r TOWN OF BARNSTABLE
LOCAT?:ON 1/ 2 41 U l�F S a Grp_ IPG� SEWAGE #
VILLAGE Ce4 -erv,t At y ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS 2 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER A r m ,deP
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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