HomeMy WebLinkAbout0007 TERN LANE - Health -7 lern Lane
�e.iftrq'ikle.
e
!t!!
low r i k,
UPC 10271
N0 H'1063 Z9?
HASTINGS, MN
TOWN OF BARNSTABLE
LOCATION `rt�w� ��'-�- SEWAGE # `��- 'I-7 f
VILLAGE -�1�� ASSESSOR'S MAP Cr LOT 2.-63 j—
INSTALLER'S NAME & PHONE NO. Leck(C:
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 04-e- vz gr- (size) joy-r
NO. OF BEDROOMS PRIVATE WELL QCBL C AT y
BUILDER"OR OWNER V���
DATE PERMIT ISSUED: {
DATE COMPLIANCE ISSUED-.
VARIANCE GRANTED: Yes No
� �
_ ���/ � /
C � � ��'��
1 � ,
t, ��-�-� ���
�.
�}
r
f
No. �.::...J.. l. FE$.... ..C ...::r
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Bisvuaal Marko Cnontitrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
............................7.... .✓ti........... .......................... -----••---....C .....�............-•--•-....----•------•------..........----•---...........-----
Loca ion-A dress d or Lot No.
O ner Add .�
-------------- ---
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms ..................................Ex Expansion Attic�-+ g— p ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther fixtures ------------------------------------------------------------------------------------------------------------------------------------------------------
W Design Flow....... ......................gallons per person per day. Total daily flow-----_2�30.......................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........l------------ Diameter.._Vd_......... 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........................
G>:, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
1:4 -----------•------------------------••-•--•---•-----•----•••••--------....-----------•-----•---•----.........................................................0 Description of Soil........................................................................................................................................................................
x
U ---•-•-•--•--•••--------------------•--•••------------•------•----......----------------•-----------••----•---------------•------------•------•----------------•-------------------•-----••-----•--•--.
w
--------------------------------------------------------------------------------------------------------------------------------------•. ---------•-•--•-----
x
U Nature of Repai{S or Alterations—Answer when applicable____?�ti� �___�xvtC _______________-t±< .� _____.........
u� ' ,z�v- ----------------------------------------------------------
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 Compliance has,b en i t board of-health.
-
Signed�� ��. ` ��.� -
----------------------- --------------
- ^^'� Dare
Application Approved By ......
' V.... ......................... ................................ ........`/..:.�p.: ��:4_
Date
Application Disapproved for the following reasons- ------------------ ------------------------------------------------ -- --------------------- ---------------------------------
................................................... ....................................................................................... .............................................................. ......................................
/ Dace
PermitNo. ..----7-;Z ------/.7 f................................. Issued .. ---- -- -----------------._ -- -- ----...... .-....--
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonstrnr#ion rami#
Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal
System at:
................---....=-7.......T�.�......�.' ........:........... ..... .4�6 ry�:........... ..... ...................----.......
_ Loc ion•A dress or Lot No.
Owner Address
�A Chi ...(..�,� _.`�7-� ...................... .5... 4??.`...._. .(r....{ (/�_t�\�.....-•-••---
Installer Address
UType of Building Size Lot.................... .....Sq. feet
Dwelling—No. of Bedrooms.... ..................................Expansion Attic ( ) Garbage Grinder ( )
a� Other—T e of Buildin
yp g ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( )
dOther fixtures .•-••-•--•-•--• •-••---•-••-----•-..........•-•--••........---•-•--•--•--.....•••••••-•-•--•-----•-•--•...............•---••-•-................•--•--
W Design Flow.......'->' ........................gallons per person per day. Total daily flow_.....?�;3.1;.).......................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........I............ Diameter...l_CJ......... Depth below inlet............... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
est
a Percolation
Test Pit NoResults minutes
Performed
r e Date........................................
Pe inch D Pth 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
Nature of Repairs or Alterations—Answer when applicable_.._,_ . _._._. r U - •. .........
.�� S l� ti:....:.... fr. s. 1__'` ......................................................-••••-•
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 Compliance has been issued-by the board of-health. _
Signed�� - d..... ..
......Date
Application Approved By ....... ...:. -•- ...... .a- --� -r-`� ............................................... ........ ..: ...... .-
Date
Application Disapproved for the following reasons: ----------------------=--------------------------------------------------------------------------------------------------------------
------------------ ..........................---------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------
^ Date
Permit No. 7 Issued .........................
..........a..----- .. ................................. Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(9 ertifirate of C�IIlrttylinuce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( 4--)__._-
b .... {. .` '..�-.! c�/�..... -c.�1a
y............................... Installer
-----------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ....../3,----......1....F.7.../............. dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................. .. . Inspector ----------....--- ............... ....................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
9 71 TOWN OF BARNSTABLE
FEE. .......
�i���a��tl nrk� �un�#rnnr�uan. .rant#
Permission is hereby granted.............
c_.` ?z.....- ...-s�T...a.l-..--C
......-•...................•--.........................
to Construct ( ) or Repair ( -)-an Individual Sewage Disposal System
atNo. `��.!�:........—....:..-....-- ...•..............• -----------q----•-•----•---•---.....--•----••---•--•---•--•-••-•--•...............--
PP P / Street _) /7�
as shown on the application for Disposal Works Construction Permit No..�/.�_.-__.,_.Y__.. Dated..........................................
�.
1 /. � . Can 0Board of Health
DATE �.-. - /,#-
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS