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HomeMy WebLinkAbout0589 OLD STAGE ROAD - Health (2) Oki TOWN OF BAR1-N�STABLE LOCATION_!;8©Q ©L1/ J1L�� , SEWAGE# VILLAGE CEO�tUt�(Q ASSESSOR'S,MAP&LOT INSTALLER'S NAME&PHONE NO. ^F� SEPTIC TANK CAPACITY l t�66G SIT, LEACHING FACILITY:(type) 50 Pky\�Oekk (size) ► • NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ����� Feet Edge of Wetland and Leachin Facility(If any wetlands exist within ZF eachin ci i ) �� Feet Furnished O Y to of a j f f C i e i, No-----3--F�---- - FEs... ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE TH �i�.-------.OF....... .- ... �LN...- ...................... Appliration for Disposal Works Tomitrurtion ramit 1 Application is hereby made for a Permit to Construct ( ) or JZepair ( ) an Individual Sewage. Disposal System at: ... a ion-Ad ess t No. �7..� 1. O e ddress Installer Address Type of Buildigs Size Lot---- -- --------S-q feet Dwelling—; No. of Bedrooms............ 7......................Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d ----Q' Other fixtures ...................................................... ---------------•------------ W Design Flow........................... -------- person per day. Total daily flow..........-3.� ------------gallons. WSeptic Tank—Liquid capacityf�_gal ons Length................ Width---------------- Diameter---------------- Depth_____________-_. x Disposal Trench—Nq_______________---_- With-_-..-.... p- 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water___________--__-____---- �Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._._--______-_.__--- 9 •------ ............................ - I ---- O Description of So1......... x U ...............--......................................................................................................................................................................................... --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature 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 Article XI of the State Sanitary 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. Si ed ---- --------------•-----•'••-----------------------•-•---------------------- ------------------------------- Dat Application Approved By. vate Application Disapproved for the following reasons:----------••------••-----•------------•-•--•---••-•-•------•---•-•-------•------------------------------------- Date PermitNo..............._......................................... Issued---- _ .......... Date r T THE COMMONWEALTH OF MASSACHUSETTS SOAR® HE A-LTH OF...... AA 4 Appfiration for 15isnooal Workii Tonotrnrtion rrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .._.r = --- - L a ion-Adess O ne dress W ,yam a = L . .. -- •••----- ---- .............4...--- -A --- _ Installer { - r Address U Type of Building, Size Lot_--._r__r P feet Dwelling p No. of Bedrooms---------------- -------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building __________ ________________ No. of persons_--____________............. Showers ( ) — Cafeteria ( ) Otherfixtures -------=-----------------------------------------------•----------------••------------------------•- -- ---------------- W DesignFlow............................. 0 ?( er erson er da Total dail flow__________--_-___ -------- .� -p P P Y• Y - --------------gallons. WSeptic Tank—Liquid capacity,/ galrons Length---_----------- Width---------------- Diameter----------------- Depth_.-.-________ x Disposal Trench—N _.................... Width.......... t Total Length._._________ Total leaching are ....._._____________sq. ft. Seepage Pit No_______ _________ Diameter_c�la_-----,Depth below inlet----- -_______ Total leaching area_ A__�-sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test°Results Performed bY------- --------------------------------------------------------......... Date---------------------------------------- i.-I Test Pit No. 1................minutes per inch Depth of Test Pit................_--- Depth to ground water_.____..____________-_-- 4, Test Pit No. 2...._...........minutes per inch Depth of Test Pit____________________ Depth to ground water-_ ---____-_____-___---- 94 ------ - )-------------- ODescription of Soil--------- G "------------------------------------------------------------ -- ---•------- ---------------------------------- 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 Article XI of the State Sanitary 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. 7SIe(dd --------------------------------................................ .............................. Da Application Approved By..--' t _1 r PP PP - h ? -------------------- ate , Application Disapproved for the following reasons:----•---•--•-------------=----•---------------------•-------------------------------- -------- -------------- ----------------------------.....................................................................................-------•-------------•---•---•----s-------------------•---------.•-.-------_.•--•-_•_.. . �t Date Date Permit No......................................................... �- --- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (Irdifiratr of T m' phanrr THIS S 0 C TI , TI e Individual Sewage Disposal System constructed (/--<Or Repaired ( ) b •--•------------ y... i --------- ........;.7 ....................... ............................................ nstaller at £ � has been installed in accordance with tl�e provisions of Article XI of The State Sanitary C de as described in the application for Disposal Works.Construction Permit No.......................................... dated.... . _., ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUE® 4S A GUARANTEE THAT THE SYSTEM WIL FUNCTI N SATISFACTORY. ................................................ Inspector---=Y------- ---..-• ....... ' THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH �%"y/���� FEE_ .................. i� �tl rk ( � lion rrmit Permission is hereby granted..- - - ------------------ --�-----•-----------•---.............................. to Construct O or pair ) an In ividual e a Di ©srt ' at No l r. .. � ' g - ----........... -- as shown on the application for Disposal orks Construction P ieet ,-str PP P / tTo.. ated f Board o Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS