HomeMy WebLinkAbout0035 OREO LANE - Health (2) 3 NO
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiuu for Uinpuual Workii Tunutrnr#iun remit
Application is hereby made for a Permit to Construct ( ) or Repair �K an Individual Sewage Disposal
System at:
a..�. ... 4. -------� .._....... L'1� 1'!/!.!_!. ...-'---'-----------------•-•-------------------------••----...--•----•-•--------.....-----------•
canon-Address ---••-------•---•--^•-•----......or Lot No.
..................... -----------------...----------------------------•-. ...
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a ��' Q.1 ✓ 4?I :..................................... .9 ®.-1 /O�I.a �j U� .�:.--•----•----
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Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms-_ -------------------------------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................ 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........................
fi Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water...-___--_---___-------.
Descriptionof Soil -----••--•...-----•--'-------•------•----------------------------------------------------------------------- --------•••-•--•-........---•----
V ...................... ---•-•----•--•-----•----...•--•-'-------•---•---•-----••----•-•---------•--••--------•--------'--•------------•••----'---------------•---•-•-------------.......-------••--------
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U Nat e of epairs or Alterations—Answ-r when applicable.--� � _ . _�/._.... .. �._� _..._. / /!"L7
..........................................
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 oardof health.
Signed :'' ter.... .. ...
Dace s�—
Application Approved By ---rr- . ----------
Date
Application Disapproved for the following reasonr: ................................................. ........ ................................ ..............
------------------------------------------------
Permit ��....... ............_......
Issued
Dare
TOWN OF BARINSTABLE
L6CA11IO1N �Q,'C-(5 �--"' o SEWAGE #
V,"-LAGE__4q WkSAI- L k ASSESSOR'S MAP & LOT.2`AIIAO
INSTALLER'S NAA-tE&PHONE NO.
SEPTIC TANK CAPACITY c N �
LEACIJNG FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PER.ML IT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted GroundwaterFacility Table to the Bottom of Leaching Facilit l Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Fee:
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 f et of leaching facility)
Furnished byC.�Cf-,-1>
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PIP—
TOWN OF BARNSTABLE Q
LOCATION �S �Q..:E r� �� .�� �•� SEWAGE #
VILLAGE.b-a �1 �15�a�8.�I' ASSESSOR'S MAP & LOT '
t
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1(oO!2j w C
LEACHING FACILITY: (type) ' O►T- (size) Git L,
NO.OF BEDROOMS
BUDDER OR OWNER
PERMITDATE: - COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
=s ;a Feet
PPY 8 rY (
Private Water Supply Well and Leaching Facility any If wells exist
. . ._ �
on site or`within 200 feet of leaching facility) ` "Feet
Edge of Wetland and Leaching Facility;(If any wetlands exist ,-,
f, 5 re,Feet
wid in'300 feet of leaching facility)
r Furnished byS�C-tom + `
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41
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphrtt#iou for Biijipootti Hforkii (fami#rur#ion rami#
Application is hereby made for a Permit to Construct ( ) or Repair (,K an Individual Sewage Disposal
System at:
L cation-Address or Lot No.
•-------•--•-----..._S l' ---------------------•----------------- --------------- .
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------------ ------- ---- -
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a /- =-• JP 7%G !"/� D. Q/7 �lJl A_
Installer
� Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms__��---------------___-_____----..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures -----------•-----•------- ---------------------------------------------------------- --- ---...........-----------------•--------------•..........---•
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
W Disposal Trench No. .................. Width.................... Total Length....__....._...._._. Total leaching a Depth.---.__-___.._..
x Septic Tank—Liquid capacity............gallons Length-------------- - Width................ Diameter--------ram sgYft.
Seepage Pit No....__---_-.---..-.-- Diameter.................... Depth below inlet.................... Total leaching area..............._-gq. 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........................
4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ---------------------------------------------------•---------......................................................................................
0 Description of Soil....... lid..............................
x
U --------•-•--•--•-•---------------•-------...._...----------------•-••-------------•-----.....------•------------------•-•--------------•-----------...-••---•-----------------------•------•--•-------.
W
U Natu e of Repairs or Alterations—Answ r when applicable...l1: .-/--_-._.._ l_%�4... __....._1 �1.. _�..
_ 50 - �� ......... / --------------------------------------------------
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 ,oard health.
Signed ----1- .. . . _. / '... �1—..��:......
l L
g - -------- j.... - .
,--
Application Approved By --=---------� � .... .... _'...`✓ .:..,��
� Date
Application Disapproved for the following reasons: .. . .. . ................. ............................
............................................. ``.....................
Permit No. /......� .... Y`... Issued ......... �`�...'.�... .
` Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t
TOWN OF BARNSTABLE
Tertifi ate of (gomplianve
T 1 IS TQ CERTIFY, Thas,the�If'dividu 1 Sewage Disposal System constructed ( ) or Repaired (,,r)
by
...Insrdler
has been installed in accordance with the provisions of TITLE 5 of The Sta e Environmental Code as described in
the application for Disposal Works Construction Permit Nq. 1 ..".. at ......" dated, `f-.-..:'"1�------- �.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL/L FUNCTION(SATISFACTORY.
---- Inspector ......................./------------�- ---- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLEG,
N............................ FE
Diopngtt1 Work j
�aIas #rr#ionrrmi# `
Permission is hereby granted-V- �-
-- _.... �__//Z.kl1------.���/(: ....................................................................
to Construct ) or Repair (Xf an Individual Sewage Disposal System
as shown on the application for Disposal Works Construction Perml o_____________________ Dated :___..f/_.....:_.._..._...............
DATE---- --•----- Board of Health
-----����--//------------------•-••----------------...-- ----------•----
FORM 36506 HOBBS 6 WARREN.INC..PUBLISHERS