HomeMy WebLinkAbout0010 MAIN STREET (CENT.) - Health JO MAIN STREET
Centerville
A = 228 - 014
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KEEPING YOU ORGANIZED
No. 12534
2-153LOR
FORE5y SUSTAINABLE MIN,RECYCLED
INITIATIVE CONTENTIO%
C-ifwFibasooroinp POST-CONSUMER
www.sFprogrom.org
SM1290
MADE IN USA
GET ORGANIZED AT SMEAD.COM
TOWN OF BARNST/A�BLE N
LOCATION�� �J'I/�l�V S/ /=G-/J SEWAGE # OO
VILLAGE 0,6urNQ I,/L�_ ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) /(size) /� /)fh
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER� G
BUILDER OR OWNER
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DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: `'"
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration fnr Di�5pwml Wor1w ( omitrurtiou Vautit
Application is hereby made for a Permit to Construct ( ) or Repair <* an Individual Sewage Disposal
System at:
` J
-•--........?�/.Q....... .s---s�z✓I SII ±.
�] Md �L^ocaGtion-i\dydr�cs / ........... ..... Lot No.
s/�
O+Zier Address
il✓.t'- ...._C7�Gt''1 ----------------------------•--------- -----------------------•---------- •---------------•------•-•-.............---
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms----------------3------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ________________--------------__ _
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity_,�.gallons Length----- Width................ Diameter_._�}r Depth................
x Disposal Trench—No. -------------------- Widt ............. Total Length----------- Total leaching area....................sq. ft.
Seepage Pit No.____.....r_._._ Diameter._. ------------ Depth below inlet..... Total leaching area..................sq. ft.
z Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed by------------------------------------------------------------------------- Date.....................................
aTest 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........................
1:4 ----------------------------------------
--------------------------------------------------------
•---
--------------------------------
..............
.....
._'••-
0 Description of Soil........................................................................................................................................................................
x
W ----- -------- -------------------------------------------------------------------------------------------------------------- ----- -------------------------•-------------••--------•-
UNature of L ai�sto,� Alterations—Answer when applicable._ _ +�... �' ...h�.<::Xe-------.
- ee �p ='�✓� � ��� �� ---#- ...."57--- R ----------------------------------
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 CeK
te of Co ce has been i ued b t e board of hea h.
igned ..... ....... ......... ----------- -- -- ------ . ..1&1.1
Dace
Application,Approved By ------- - ------- -------------- .... .....®..... .. .
--- -. ----------- --- -- --............ ---------------ice-----------
Application Disapproved for lowing rearons:
------ ........... ----- ---- ---------- ----------------- ------------------------------------------- -- ------- ----------
® Dare
Permit No. ... .- - ...( .. - Issued ....._....... T -------------- ------
No..... _.. FEB
L
THE COMMONWEALTH OF MASSACHUSETTS
,, !f BOARD OF HEALTH
TOWN OF BARNSTABLE
�t" tt
,� lirtt#matt �nr �t,� � ,�ul �lark,� C��tt,�#�� � rrtr#tort ramit
Application is hereby made for a Permit to Construct ( ) or Repair �< an Individual Sewage Disposal
System at: !
Location• \ddress q j'x rvti! i'` ,n `. r or Lot No
--------•--•-- t--•----------------------------------•---------.
Ow er Address
a ---------- C °2 .................------------_---------- ......
Installer r" / Address
t ------------Sq. feet
U Type of Building � Size Lot_______________
Dwelling—No. of Bedrooms------------ -- -----------------------Expansion Attic ( ) Garbage Grinder ( )
I
`L4 Other—Type T e of Building ------------- x _---._.---- No. of persons :-.--_..__ Showers ( )0.1 YP g ---- P ( ) Cafeteria
04 Other fixtures . i ----------------------------------------------- -------------------------------------------------------------
W Design Flow............................................gallons per,..person Der'day. Total daily flow............................................gallons.
Liquid ca acity ns Length-_
-- ------ Width__..WSe tic Tank— i _� g�Mo _--_--_-- Diameter •------ Depth................
Disposal Trench—No. -------------------- Width------------- _ Total Lerigth----------- __.____ Total leaching area-----__-___--------sq. ft.
Seepage Pit No..__._._-_�...__ .. Diameter.__(D.............. Depth below-inlet_.._.. ____.__. Total leaching area..................sq. ft.
Z Other Distribution box (�) Dosing tank ( )
�' Percolation Test Results Performed bY----------................................................................ Date........................................
1_4 Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.-.----.--_--_-_-_- Depth to ground water........................
1:4 •--•------•----------------------------------------•---•------------------------------------._...............................................................
0 Description of Soil----------------................................................................... ------------- ------------------......--•--.....---------------•--•...............
x
V --••-••--------- -•-----•------••------------ ..........................------•---•---•-•---------------•--•--------------•-------•---------- ---------•----------•------------•---•..................
W
--------------------------- --------------------------------------------------------------------------------- - .
U Nature of Re�r�sror Alterations—Answer when applica le.__ ____41Z____ ________ --------------
_____~.-..
-. ----------
r
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
t e board of hea h.
-
system in operation untila ert ate o o ce as been issued
ed ----------
- �b.Ar..) ..
Dace
l Application Approved By .. tk .. ....a /------ ---
.- -------- --------.......Dace-'---`----------
Application Disapproved for the following reasons: ---------------------_.........:_...---...._..........---......----------------------------_
. . �..�....• .. /'�/�� ....._ /
...... . ............--- - -- Dare
Permit � ---- ----- Issued ---------- . ......./ Dv.
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Terttftctt#P of Torayliance
THIS IS TO TIFY, Th th Individual Sewage Disposal System constructed ( ) or Repaired (�')
--`✓ �-t� -----------------...................----------------- -..._------------------------------_ ---------- ------------------.._.. ..
by _..._..-
h d),
at ........................./_.1>_ ... ( ....... T....._.._... ..................._...... ........ ................
has been installed in accordance with the provisions of TITIV oLlhe St to Environmental Code as described in
the application for Disposal Works Construction Permit No. 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
p� BOARD OF HEALTH
V 0 TOWN OF BARNSTABLE �-
No. FEE...............
rkii (tart t #ion rand#
Permission is hereby granted---------------
to Constr t ( ) o pair ) an divi ew�gg_Dis s ys
J --...
Street /
as shown on the appli tion for Disposal Works Construction P r 't No... ate Vd' .. .._�...................�i._b.
1
Board Health
DATE --------•-----------------
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
C/ TOWN OF BARNSTABLE
LOCATION'10 /911;11,y ST� f ,Qi�"/_ SEWAGE # OD
VILLAGE C�jifTiQ IflCGi% 2 z
ASSESSOR'S MAP 6 LOT i
INSTALLER'S NAME & PHONE NO. M(-e,-
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) �, ( �� (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERjgjh' ,
BUILDER OR OWNER /,jq�//� 411hx
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VA41-IANCE GRANTED: Yes No
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