HomeMy WebLinkAbout1131 OLD STAGE ROAD - Health 1131 OLD STAGE ROAD
Centerville
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Fss... 4............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J- .... oF...:...... , � ----------------------- ------
Apptiratiun for Uiipuual Works Tomarnrtiun Famit
pplication is h made or a Permit to Construct ( ) or Repair (&_.�an Individual Sewage Disposal
st at:
�¢.
- ....-- — ----- --•- ---•--. ... .. .-•-----• • •-- .....
ocat n-Address Lot.No
Owner a
. ....................Address .
Installer Address
VT. e of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms..............._....................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water...... 17,0
LZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
O Description of Soil........................
W
U ---••------------------•--•-----...._..--------•----------------------------••--•-•----••••••-•-•.............-------•--•----------------••-.....-----------•------•----------•------------------....---
W
V Nature of Repairs or Alterations—Answer when applica-le---------------------____________
-- -----------------•------•---•....-----•--...........-----•-•--------------------........--- - , 5 ----------------------•--•------•--------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI.i� 5 of the State Sanitary Code—The u0or
Zhealh.
r agr t to place the system in
operation until a Certificate of Compliance ha been issued b Signe . --- .------ ----•--•--------------• .....���...^
ate
Application Approved By.......... . • --•--• ------------------------------------ ---••-----� � ' .
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------•---------------...------...•••.
--•......-•....................•---••---...--------------•-------•---•-•-•------••------•...-•-•-------•.•----------•---•-----------•------------•----------------•-•--------------------------...------
Date
Permit No......../._V.. ?�--•---•--•-------. Issued............................
...........................
1
' No.,�.G��................ Fps..., ..4...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ..............OF.....� / •e*'- /_ ................_..............
Applirtttion for Dispoiial Works Tonstrortion ranfit
Application is hereby made for a Permit to Construct ( ) or Repair (W'�an Individual Sewage Disposal
System at:
................_................................................................................ -..----•----.....--------•--•----••--••-•-•-•-----•-•-•-----------.-..---------•-•---•----------•-
,i 6 /' t ,��ocation Address Ile
/ o'r Lot 11 No: J�
••............ .............................. .................................................
Owner Address
Installer Address
t �
Q Type of Building Size Lot............................Sq. feet
U Dwelling-No. of Bedrooms............. -----_'Expansion Attic ( ) Garbage Grinder ( )
a Other—Type T e of Building ... No. of persons............................ Showers — Cafeteria
A� YP g P ( ) ( )
Q' Other fixtures --------•--------•----------------•--•-•••......•......Q ------------------------------------------------------- -------------------
W 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water..... _
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' --•------ -0-e.......................................................................................................................
Descriptionof Soil...................... R.4e,-Z..........................................................................................................................
W
-----------------------------------------------------------------------------------------------------------------------------------------------------------------••-----------•---------------._------
U Nature of Repairs or Alterations—Answer when applicable----------------------------------. .s....__ ........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T Li 5 of the State Sanitary Code— The unde�kned further agr at to place the system in
operation until a Certificate of Compliance ha been issued by U1 e bo rr of heaNh.
Signe ._.,:. .. �r-------------- ......-----------••---------•--- .. ...-•----`--
Application Approved BY-•-••-••-_ ---.... .' e_'... /
Date
Application Disapproved for the following reasons:.......................................... ----•----•--••••--••-•---•-----------•--••----•---•-••-••-•-......••--
••------•-•-----•••--•-•••--•----•-----•---•-•-•.---••-•----•-----•------•-•-••---------•-•••••-•-----•-----•--•--•-•--•--••-----•---------••---•-•...-•-•-•---••••-•---••------•...-••-•---.-•••-•_.._.
�f Date
PermitNo........ • •------��---------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T rtifiratr of Toutplitturr
THI Ir TO'C�ERTIFY, the Individual Sewage Disposal System constructed ( ) or Repaired ( .
by.................�.•1 . -•-••.....................•----.......•• --------- ---....-•-_.. ..._._._........--•-••••••. •-•-••----.............
,r +—.Installer
t -----•... W,a f _��� l�............................................l a -----F 1.r .;.............................................. ------------------------
has been installed in accordance with the provisions of ry'.TIZ `?• of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..............1�._........ .?.. dated.................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE_.......�._..:�..� .�......--•............................... Inspector- ---..
"�7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH_
..............OF.......
c+.? .. ¢ ..................... Q...
No.. FEE.
Dioproal orkii Cons wit rrotit
Permission is hereby granted.... �
to Construct ( )for Repair a. Ytfdividual. Sew age Disposal System /J /
Z1.11
Street
as shown on the application for Disposal Works Construction Permit No.3_.r_ ._ __. Dated..........................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
a. t
TOWN OF BARNSTABLE
_ 'LGCz'_ ON ' I I 014 4e4 ge JOw SEWAGE # 90 " 9 7
Now
(.. n VILLAG ASSESSOR'S MAP & LOT p 02b✓60I
INSTALLER'S NAME St PHONE NO. . a- Dt°5 �d�l F771 361
SEPTIC TANK CAPACITY 1 S�OC) O 4 d6k-c
o
LEACHING FACILITYAtype) '" -low dr r�5"rs (size) S"�►o�i
NO. OF BEDROOMS 3 PRIVATE WELL R PUBLIC WATER
BUILDER OR OWNERd c 1 �►hh e c
DATE PERMIT ISSUED: —7 Z `Ip
DATE COZIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
Nrlit
Y
TOWN OF BARNSTABLE
LOCnliON ( �Li I l Sfei oe �Ow SEWAGE # 9
Now
VILLAG �ASSESSOR'S MAP & LOT
INSTALLER'S NAME Cz PHONE NO. T. J - s c a
SEPTIC TANK CAPACITY Q A t(O k t
LEACHING FACILITY:(type �ldW d, (size) wX Ll S"►�°lei
NO. OF BEDROOMS 3 PRIVATE WELL R PUBLIC WATER
� p
BUILDER OR OWNER 1Rd t ai c ni' 0111f, r
DATE PERMIT ISSUED: / / / qp
#
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
sy.
7INSTALLER'S
TOWN OF BARNSTABLE
IONI L� L �I� S7�1Ge SEWAGE #
E ✓l tC�U 1 ASSESSOR'S MAP & LOT/7-3
NAME & PHONE NO. 6�Qv�Uciec cacp TANK CAPACITY o2000 9c.
LEACHING FACILITY:(type) CeSw(54n (size) a6n 6
NO. OF BEDROOMS _� PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER e r Ca
DATE PERMIT ISSUED:
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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TOWN OF BARNSTABLE
LOCATION_1 [�( � �� Q S�q j SEWAGE #
I�ILLAGE ASSESSOR'S MAP & LOT/7-3
INSTALLER'S NAME & PHONE NO.(�6"C'eyl�C;�� -77/-M t G
SEPTIC TANK CAPACITY o200 O
LEACHING FACILITY:(type) CeSS,pod [ (size) ab0 c7
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER o r'
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED:. Yes No
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