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Home My WebLink About0119 POND VIEW DRIVE - Health 119 Pond View Drive Centerville A = 229 - 027 �JAcrcLeotlo�Z !U! � NoPC LOR HASTINGS,MN v 1 V q �4 No.. -.—f. Fss.. ............ THE COMMONWEALTH OF MASSACHUSETTS -BOAR® OF HEALTH ...........................................O F....................--...----..._.........--•-----......__....__.._..._...-- App iration for Bi.spnsa1 Works Tonstrnrtion WrWit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ............ _...C...° Y.U.I!e ----•-------•lam--. C� /7L _tJ.. �P-------------•--- Location-Address or Lot No. .................................... .................. tOMess Owner....M..A..>�_l./_Y_...._ �... .----...J��._lf._ �� .....11 --___---•----• ,FI !'U1...... ^.............. Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............3.........................Expansion Attic ( ) Garbage Grinder ( ) p`4 Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- - d --------------------------------------•-----------------------•------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.,l#?a4-gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit Noll*0.3 tI_-- 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_-______________-_____-. fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----------•--------------------------.--•-•-----••-------------••---------------.....•-•....._-••••-......................................................... 0 Description of Soil........................................................................................................................................................................ x U ------ --- ---- = --------------------------------------------------------------------------------------------------------------• � `................. 7 U Nat of Reirs or Alterations—Answer when applicable--�_._ ._� :v- K_ ____-___I_-_______3 _._`aS..-.-. -----•-•---••--•----•-------------------------------------------------------•----...------ -----------------•-------------------------------- .............................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI,E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be sue y the board of health. Signed------ .. Date ApplicationApproved By................................................................................................... ........................................ Date Application Disapproved for the following reasons------------------------------------•--------------------------------------------•------------------------------- ---•................•-•••••-...---•••----...---....•----------.............------•-•••-----._..._..-----•---•----------------------------------------------------•--------------••--------••------....•- Date PermitP4o......................................................... Issued............................. _ Dates ... ....... .. ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------- --------- ------------------------OF................................_......---------------........-----------........._._..... ApplirFatinn for UiipnsFa1 Works Towitrnr#inn rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at ew �' ..... �. .. / ( f .Location-Address or Lot No. Owner Address -•-• ..... --......•------------------...._..----- .•• •-----......----.................--•..... .... ------------------•---•-----•--- � �-•---°--•-•--•-•------•-••-•--•-•- Address Installer ; UType of Building Size Lot............................Sq. feet .-, Dwelling—No. of Bedrooms.................-�.r_.........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) f-4 Other fixtures -------------------------------•-•-•------------------------------------------------------.. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity...o��._'`!gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No../..�.QP__St.L Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box`( ) Dosing tank ( ) Percolation Test Results Performed bY-----------.............................................................. Date........................................ �4 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........................ P ----------------------------------------------------------••---...--------.......-----------................................................................. 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 TITLIJ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeltrissued-b}y the board of health. Signed.............. t > 4ft' ate ApplicationApproved.BY--------------------------------------------------•---------...................---•-•------•--•-•- ........................................D .. Date Application Disapproved for the following reasons---------------•--------------------------------------------------------------------------------------....._..... --•-•-•-•-----•--------------•---------------------•-•-•-------•--....-•---------.........--------.......I--------------••------------------•----------•----------------------------------------•-------- Date PermitNo......................................................... Issued-............-.......................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of Tnmph anrr 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 TITIZ 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED .S A GUARANTEE THAT THE SYSTEM WIt,A. F TION SATISFACTORY. t , DATE.�.'Z ..................................................................... Inspector..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......OF....................... No.. FEs.. .:. .... v0o' Permission is hereb. grante to Construct (� ) or air : ).. an ndividual Sewage Disposal System at No............. 1 •... --------------------------------------------------------•--------------....-------------------•-•-------•-----•--........... Street as shown on the application for Disposal Works Construction Permit . .................. Dated.......................................... ................... ...• ••-••------•-•--------- --------•---••------••----------•-------_..._ Board of Health DATE.... -��..�3..--•-----•----------------•----•--•---•---••--- FORM 1255 HOSES & WARREN. INC.. PUBLISHERS LOCATION / SEWAGE PERMIT NO. I I �rv,N lJ7 VILLAGE 1 N S T A LLER'S NAME i ADDRESS j r7l/ w 7 17 BUILDER OR OWN R DATE PERMIT ISSUED DATE C0MPLIANCE ISSUED �� b F. r .L Postal Servicer,, CERTIFI�D MAILP., RECEIPT —I ^�1 D• No Coverage Provided) 1 U CO For delivery • 1 rnQD Lr) A\b �information I C qri eaE1 pg Ln Postage $ .�-Y4 '`'G'!9—rq p Certified Fee. S r pp Retum Reciept / 6'� Postmark (Endorsement Requ e r 5 J CRestricted Delive Fe M�., �/fn� (Endorsement Req r 2W r0 Total Postage&Fes m p Went To , p NIA. T',ch �te L� � -et, fo.;----- --------------• ---- - -- r Apr.n ` --�---------•---- or PO Box No. 11q v%ew -------------------- ............--------------------------------- City,scar®.ZIP+4 M h ace 3 a Certified Mail Provides: (esianag zoozounr'oosewjodSd ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. r Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Retum Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed;detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if F3estricte6Delivery is desired. L t— ■ Print your name and address on the reverse X d eSSL so that we can return the card to you. B. Received by(Printe Dat of elivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1 ❑ es 1. Article Addressed to: If YES,enter delivery address below: ❑ No C e-4e-,Cr V\ \\2, AA O Dace 3-1, 3. Service Type ❑Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7003 1680 0004 5458 2858 (Transfer from service label) PS Form 3811,August 2001 Domestic Return Receipt 102 595-02-M-1 540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS P'Trm`it No 'G-10 • Sender: Please print your name, address, and ZIP+4 in this box • I Department of Public Health Town of Barnstable 200 Main Street Hyannis, MA 02601 - J ��•��= 111 11 11 -Ili I` IIII II III t v O I a 0