HomeMy WebLinkAbout0220 COMPASS CIRCLE - Health 220 COMPASS CIRCLE, HYANNIS
A=310-410
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and get the Business Certificate that is
required by law.
DATE: /f�/i3/Z0/7 Fill in please:
APPLICANT'S YOUR NAME/S: F•FIQ/O o5O/�eJ
BUSINESS 9 '
',';��.t,•r..�+t:" Pilo p.�.jt}'
YOUR HOME ADDRESS: 90 CJ�a� 55 C/reCl N Y�rvr��S
I>,I:r�•s•>,;;:�;i,.,..er4 ;Y �;aa��.;'
3CO345,7
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TELEPHONE # Home Telephone Number
r•' ,i�'.!d%vi t %-� SOC I AL SECURITY OR E I N #: p
J /r $�.�.3�6 E-MA I L:FAd>ivHo;zi�7
NAME OF CORPORATION:
NAME OF-NEW BUSINESS ,rF Tel TYPE OF BUSINESS ?/Ge /.t/3TX�,
IS THIS A HOME OCCUPATION? V YES NO
ADDRESS OF BUSINESS.ZZO..CO�P S CACC,C�G ~Awl -��- ae'v'o / MAP/PARCEL NUMBER _ 1 0 — y � � (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. [corner of Yarmouth '
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONERS F ICE ? ram. MUST COMPLY WITH HOME OCCUPATION
This individual has bee f ed of any r " t requirements that pertain to this type of businessRULES AND REGULATIONS. FAILURE TO
,Authorized Signature** OMPLY MAY RESVLT IN FINES
l v i
COMMENTS:
2. BOARD OF HEALTH
This individual has been inf r e permit requirements that pertain to this type of business. MUO COMPLYWITH ALL
HAZARDOUS MATERIALS REGUC.AIQNS'
Authorize Signature**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
TOWI``OF STABLE b CI
�° �
LOCATION C)��' SEWAGE 0�000
VILLAGE -AV i�9.n�ifz�y^a ASSESSOR'S MAP & LO
/I
QAV
STALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNE
t
PERMTTDATE: 0, 6 COMPLIANCE DATE: '611o�
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 Leaching Facility(If any wetlands'exist
within 300 feet of leaching facility) Feet
Furnished by
•a• a
i
v
TOWN OF BARIJSTABLE ----
LOCATION_ U0 C
SEWAGE 0�zo 1
VII.LAGE p / ASSESSOR'S MAP &LO /
j INSTAL,LER'S NAME&PHONE NO. i .
SEPTIC TANK CAPACITY ov o
LEACHING FACII.TI'Y: (type) )
(size
NO.OF BEDROOMS
BUILDER OR OWNER
i
PERMITDATE:
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)
Edge of Wetland and Leachin Feet
g Facility any wetlands exist
`..within 300 feet of leaching facility)
Furnished by Feet
No DnOt— �.�� Fee (l
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Mi000l *Peu u Cori.5truction Verna
Application fora Permit to Construct( )Repair( )Upgrade('ice)Abandon( ) ❑Complete System individual Components
Location Address or Lot No.000 Co ���C � Owner's Name,Address and Tel.No.
Assessor's Map/Parcel U'"'l r o �EJ_4 �., 1
1� r
Installer's Name,Address,and Tel.No. r Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flows Z gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank IE Type of S.A.S. \T&,(.a ur,l f:c_
Description of Soil �li.cQ r Q 012s� soad,An
Nature of Repairs or Alterations(Answer when applicable)
(Aid{
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code a o place the system in operation until a Certifi-
cate of Compliance has ���ea
Signed Date67—��`�
Application Approved by Date 'F-_ 16_00
Application Disapproved for th follo ' g reasons
Permit No. -3tt0c -- Date Issued
'No: C�0 — .�.J ':; Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
application for Migpool *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( Y-)Abandon( ) El Complete System 2%dividual Components
X:
Location.Address or Lot No. M \d c Owner's Name,AddressYand Tel.No.
Assessor's Map/Parcel i5 Q((n f�j T__
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
s►- E-
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow i i-? gallons.
Plan Date Number of sheets Revision Date
Title
r Size of Septic Tank s t v . t 0 VS Vc 4i Type of S.A.S. Q 6,C_`r4
Description of Soil 6C3,P
a f �
Natur of Repairs or Alterations(Answer when applicable)
��t�- y, �.L� ��{ C.t`�� �,�0�-;Lc �...�d`G'1-�U��s (rJ�� �i CJ{c; ': C✓'it-.' �> /,�'�'-f n`.--�'''
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and-ne-to place the system in operation until a Certif-
cate of Compliance has bw— -issued-b ealt . 9
Signed
-_- Date _.
Application Approved by Date r- /6,-02
Application Disapproved for the follow g reasons..
Permit No. AO08 2,040 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded
Abandoned( )b Pik
at \A`(fin.a S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 76 dated
Installer a Designer {
The issuance of this a so o be construed as a guarantee that the s em 11,function as designed/ f s
Date s.. rye�.,� Inspectors'!f �,f` 'rr f df '
---------------------------------------
No. !J�(/�— �.f(o Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-- BARNSTABLE, MASSACHUSETTS
'wigpooai Opotem Construction Permit
Permission is hereby granted to Construct( )Repair( . )Upgrade(ti5Abandon( )
System located at (✓` e .
_ t� hvdy 1
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: 5 -lG d Jo Approved by � �
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated (��`(� , concerning the
property located at C-o Yw 44 u f e_ �-}`�� meets all of the
following criteria:
(This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
_• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
44/"There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
L•� There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
*--"'The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
�plicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following: �} a
A) Top of Ground Surface Elevation(using GIS information) `� 1
B) G.W.Elevation D�iL9 +the MAX. High G.W.Adjustment l'
DIFFERENCE BETWEEN A and B r4
SIGNED : DATE:
[Please Sketch prop ed plan of system on back].
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
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Z 273 502 597
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
Sent t
Stregt&N m r
7�r
P i e ate,&Z Code
Postage $
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
LO
rn Return Receipt Showing to
Whom&Date Delivered
Q Return Receipt Showing to Whom,
Q Date,&Addressee's Address
0 TOTAL Postage&Fees $co
a
CO Postmark or Date
6- 3
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge). In
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q)
return address of the article,date,detach,and retain the receipt,and mail the article.
LO
3. If you want a return receipt,write the certified mail number and your name and address rn
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a
I RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the G
!E 00 addressee,endorse RESTRICTED DELIVERY on the front of the article. 00
I CV)5. Enter fees for the services requested in the appropriate spaces on the front of this E
I receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. 0
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6. Save this receipt and present it if you make an inquiry. 102595-99-M-0079 a
Town of Barnstable
Department of Health, Safety, and Environmental Services
iUWMBLE,
9� 1659.
,e Public Health Division
P.O. Box 534, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
May 3, 2000
Mr. Martin Coyne
134 Shores Road, RFD 8
Plymouth, MA 02360
NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE
ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE
SUBSURFACE DISPOSAL OF SANITARY SEWAGE,AND 105 CMR 410.00
STATE SANITARY CODE H- MINIMUM STANDARDS OF FITNESS FOR
HUMAN HABITATION.
The property owned by you located at 220 Compass Circle, Hyannis, was inspected on
April 4, 2000 by Donna Miorandi, R.S. Health Inspector for the Town of Barnstable,
because of a complaint. The following violation of 310 CMR 15.00, the State
Environmental Code, Minimum Requirements for the Subsurface Disposal of
Sanitary Sewage and 105 CMR 410.00 State Sanitary Code H- Minimum
Standards of Fitness for Human Habitation was observed:
REGULATION 310 CMR 15.02 (207) AND 105 CMR 410.300:
Overflowing sewage onto the ground. This violation is a serious public health hazard.
1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool
within twenty-four (24) hours of receipt of this letter.
2) You are also directed to keep the on-site sewage disposal system pumped as many
times as necessary to keep from overflowing onto the ground.
3) You are further directed to contact and hire a licensed Disposal Works Installer within
seven (7) days of receipt of this letter in order to repair this system or connect to town
sewer.
You may request a hearing before the Board of Health if written petition requesting same
is received within seven (7) days after the date the order is served.
Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with
an order shall constitute a separate violation.
ER F HE BOARD OF HEALTH
o as A. McKean
Director of Public Health
1
f
0
l
NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE
ENVIRONMENTAL CODE TITLE V: MINIMUM REOUIREMENTS FOR THE
SUBSURFACE DISPOSAL OF SANITARY SEWAGE, AND 105 CMR 410.00
STATE SANITARY CODE H- MINIMUM STANDARDS OF FITNESS FOR o
HUMAN HABITATION.
TheV ned by you located at�listed as Parcel on Assessor's Map w s inspected
on , Vbyj06Q !'�/G1flIealth Inspector for the Town of Barnstable, because
of at. The following violation of 310 CMR 15.00, the State Environmental
Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and
105 CMR 410.00 State Sanitary Code H- Minimum Standards of Fitness for
Human Habitation was observed:
REGULATION 310 CMR 15.02 (207)AND 105 CMR 410.300:
Overflowing sewage onto the ground. This violation is a serious public health hazard.
1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool
within twenty-four(24) hours of receipt of this letter.
2) You are also directed to keep the on-site sewage disposal system pumped as many
times as necessary to keep from overflowing onto the ground.
3) You are further directed to contact and hire a licensed Disposal Works Installer within
seven (7) days of receipt of this letter in order to repair this system or connect to town
sewer.
You may request a hearing before the Board of Health if written petition requesting same
is received within seven (7) days after the date the order is served.
Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with
an order shall constitute a separate violation.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
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'� 310410 1� x: V AA,u Q � 002295 0000000 �° 1, �
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`� 4t� LOT 24 A ��• ' 'Yl� 1, .23 �� a�f _,� 4
COYNE,MARTIN J& Tte ass 101
MYR,SYLVANA � � ��Q Btd 1 � 4� 00001080 '\F
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PLYMOUTH MA 02360 a s a 00-0000 000
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COMPASS CIRCLE > 0340 9 0127 '
ire st' HY VW eItel_ . 0000
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Z �73 502 683
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
Se -
St &Number
Post is State,&ZIP C
Postag
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
rn Return Receipt Showing to
Whom&Date Delivered
n Retum Receipt Showing to Whom,
Q Date,&Addressee's Address
.0 TOTAL Postage&Fees $
M Postmark or Date
LL
I
`I.
4 Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service .'
window or hand it to your rural carrier(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q)
return address of the article,date,detach,and retain the receipt,and mail the article. �
LO
3. If you want a return receipt,write the certified mail number and your name and address rn
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the
O
addressee,endorse RESTRICTED DELIVERY on the front of the article. co
� M �
5. Enter fees for the services requested in the appropriate spaces on the front of this E
j receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. li
I
i 6. Save this receipt and present it if you make an inquiry. 102595-99-M-0079
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Town of Barnstable
Department of Health, Safety, and Environmental Services
MUMSTAUX
"�: ��� Public Health Division
�FDAAO�A P.O. Box 534, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
January 13, 2000
Martin J. Coyne
134 Shore Road RFD 8
Plymouth, MA 02360
NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE
ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE
SUBSURFACE DISPOSAL OF SANITARY SEWAGE,AND 105 CMR 410.00
STATE SANITARY CODE H- MINIMUM STANDARDS OF FITNESS FOR
HUMAN HABITATION.
The property owned by you located at 220 Compass Circle, Hyannis was inspected on
January 11, 2000 by Donna Miorandi, Health Inspector for the Town of Barnstable,
because of a complaint. The following violation of 310 CMR 15.00, the State
Environmental Code, Minimum Requirements for the Subsurface Disposal of
Sanitary Sewage and 105 CMR 410.00 State Sanitary Code H- Minimum
Standards of Fitness for Human Habitation was observed:
REGULATION 310 CMR 15.02 (207) AND 105 CMR 410.300:
Overflowing sewage onto the ground. This violation is a serious public health hazard.
1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool
within twenty-four(24) hours of receipt of this letter.
2) You are also directed to keep the on-site sewage disposal system pumped as many
times as necessary to keep from overflowing onto the ground.
3) You are further directed to contact and hire a licensed Disposal Works Installer within
seven (7) days of receipt of this letter in order to repair this system or connect to town
sewer.
You may request a hearing before the Board of Health if written petition requesting same
is received within seven (7) days after the date the order is served.
Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with
an order shall constitute a separate violation.
PER QJMER OF THE BOARD OF HEALTH
o . McKean
Director of Public Health
coyne/wp/q/ls
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Town of Barnstable
Department of Health, Safety, and Environmental Services
DAEIV3PASM
Public Health Division
RFD"" A P.O. Box 534, Hyannis NIA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Q� Director of Public Heallthth
r� � W To C��i �� K)4 Y 13) �000
13� J I e 0� rwh r) ICI D 4?
� h> e Kam
1 ater D
Cen 0263
NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE
ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE
SUBSURFACE DISPOSAL OF SANITARY SEWAGE, AND 105 CMR 410.00
STATE SANITARY CODE II- MINIMUM STANDARDS OF FITNESS FOR
HUMAN HABITATION. � ,o eompliss C/pe1e-) 019741iols
The property owned by you located at , was inspected on .
Donna Miorandi, Health Inspector for the Town of Barnstable,
because of a complaint. The following violation of 310 CMR 15.00, the State
Environmental Code, Minimum Requirements for the Subsurface Disposal of
Sanitary Sewage and 105 CMR 410.00 State Sanitary Code II- Minimum
Standards of Fitness for Human Habitation was observed:
REGULATION 310 CMR 15.02 (207) AND 105 CMR 410.300:
Overflowing sewage onto the ground. This violation is a serious public health hazard.
1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool
within twenty-four(24) hours of receipt of this letter.
2) You are also directed to keep the on-site sewage disposal system pumped as many
times as necessary to keep from overflowing onto the ground.
3) You are further directed to contact and hire a licensed Disposal Works Installer within
seven (7) days of receipt of this letter in order to repair this system or connect to town
sewer.
You may request a hearing before the Board of Health if written petition requesting same
is received within seven (7) days after the date the order is served. Non-compliance
could result in a fine of up to $500.00. Each day's failure to comply with an order shall
constitute a separate violation.
PWoma
OF THE BOARD OF HEALTH
s A. McKean
Director of Public Health
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SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Received.by(Please Pri 1 ar ) B."Date of Delivery
item 4 if Restricted Delivery is desired 4 2000
■ Print your name and address on the reverse
so that we can return the card to you. C. ignatu e t
■ Attach this card to the back of the mailpiece, ❑Agent
or on the front if space permits. ❑Addressee
D. Is delivery a dress di event from em 1? ❑Yes
1. Article Addressed to: If YES,enter delive ddress b ow: ❑ No
/b 3. Service Type
d' 10 Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number(Copy from service label)
itft f f:flillji tt 'I ., r r
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PS Form 3811,July 1999 Domestic Retur'n'Receipt 102595-99-M-1789
UNITED STATES POSTAL SERVICE Firs- lass-Ma'
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• Sender: Please print'ayour`name;address, and'ZIP: in-this`6ox' o
_ a
Public Health Division t
I ;,own of Barnstable
R0.Box534
I hyannik Massachusetts 02601
I
LO A I SEWAGE PER T 0. \
r'
ILLAGE 7oC7
INSTALL R S NAME & ADDRESS
a w
BUILDER OR OWNER
DATE PERMIT ISSUED �(2�
DATE C ® MPLIANCE ISSUED �� � ��
i
7.5---,,
1
LOCATIO "" SEWAGE PERMIT NO.
'r
VILLAGE
INSTA LLER'SS NAME & ADDRESS
BURDER OR O NER
DATE PERMIT ISSUED _
v
DATE COMPLIANCE ISSUED
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1
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No......... F:ss.. ,s''�.C/.. .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
... .... .........................OF..........:................_ .
Applira#iun for UWposFal Workti Towitrurtiun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
e.
Locatio ress or Lot No.
�� A • _ �-t. ............. r..-.....•........------.........................
O er Address
a •. ................................ .......................••-----•--•-
Installer Address
Q Type of Building Size Lot---���__!jm_p-----Sq. feet
Dwelling—No. of Bedroom --- ..................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building _ D No. of persons.......... .............. Showers ) — Cafeteria ( )
Q' Other_fixtures ........... ........
d
W Design Flow..-.5 ...............................gallons per person VerVAY. Total daily flow......�.40........................gallons.
WSeptic Tank—Liquid capacity._�nd�..gallons Length.A............ Width......`f...L Diameter................ Depth................
Disposal Trench—No. __________________ Width...._............... Total Length_._................:Total leaching area....La�,�: .sq. ft.
----. Diameter.................... Depth below inlet................... Total leaching area................._s ft.
� Seepage Pit No �"�.___ p g q.
Z Other Distribution box ( ) Dosing to ( )
Percolation Test Results Performed b -__/��. "�Yl��✓....��!s�.��!'fR�✓...... Daten:� ...�S^.
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground
G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------------------------------
- ----------------
•-------
-----•--•-•------
-........
.....................
----------------
•--•--
®. Description of Soil....of;
�+f �'/fjv.l.At....----•---------------•---------------------....----------------------------------•-•---------------•---•-•---------------....--•-•-----
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--•-----------------------•-------•---------------•-----.----•--------------------------•--•-------------------------------•--•-----------------
W -•••---••---------------•---------------•--••----------•-•-•---------•---•--••••-•---•-••----•----•-----•--•--•--•---•--•----•-----•----•-•----•--•---------•-----......---------------.......---......
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 iIT1.;,,. 5 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 t4eboard of h alth.
Signe •-----------------l�®'U/iy�...
Application Approved BY =`-------------------------------------------------------------------------------- --...��.� �� ..._.-
Date
Application Disapproved for the following reasons:............................................................................................ ..............
--••--.......---•----•--•.......................•--------------------•-----••----•----.........--•-•------•---•--.....-•----•-••---•---•-•-•-••-•••---••-----•-------•-•------•••--•---•-•----..........
_ Date
PermitNo...... ........................................ Issued-.......................................................
Date
.yNo. ---7 ..... — Fps.. ..5.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..........................................................................................
ApplirFa#ion. for Disposal Works Tonstrnr#iun Prrmit ,
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: / -lie
....f.::...._..........r'� ! `! ............................................... ....c....................................... .......... ......
Location�i=A dress '-7 or Lot No.
.. 7 .. �:.................•........--•-••----•---•----•--......--•----•---...........................•
.. __. _•
i Owner Address
a �...........:............�_........... ..................................... ...---•-----•-••-•------........_............................._.............................-•-
pq t/ Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...... ::.................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e
a —Type of Buildin g ..:.......................... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .. ._.._... ------•--------------------......--•-•-•-------------------------------•--••------•-•--------------•.......--•---•----
W Design Flow............................................gallons per person per day. Total daily flow...._._......a......................_....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 ( ) f
' ' Percolation.Test Results Performed by....l'f`.. .``' ` ----- Date-r!_.......: .......%.
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water__'` '..:_. .
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.---....................
a' .-.--•-------------------------------------•--•-••--•-------................----•-••-•-------------................-•-•--•-----------.................---._----
D Description of Soil....L.__
x
U ..................................................................................------•-•---------•----------------.......-------•-------------•-----•--------..........--•-----•-......--•------••-.
W
-------------------------------------------------------------------------------------------•-•---------------------------------------•---------------------.....---•------....---...............__...--
M. 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'TT .
5 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.
Signed_ <✓._:'. --------------
- „� -----•-------•--- ................. r
f /�1
%
y CDate 4-
Application Approved By-•----••.�. .
Date
Application Disapproved for the following reasons:-------•----------------------------------------------------------------.......................................
............................•----•--•-------•-----------......---•----------------•-----•--••-----....----•-------------•-----•--••---•---••----...---------••-------•--------------•-•••--•---•••.-----
Date
PermitNo....... 1 .. ...................................... Issued•.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
Tntifirate of Tomplianrr
THIS IS TO CERTIFY, That the.rIndividual Sewage Disposal System constructed ( !) or Repaired ( )
by....-- : �.:.t':... !:... .... - - f':-
' Installer
•--•------•.................•-----------•-•---•------•-----.....----•----•--. ---••-•-•---•••--•-•----------------..--...............--••--•-•---•----•--•---------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..--..7 ... ........................ dated--...-: .....................
r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRI! AS A GUARANTEE THAT THE
SYSTEM WI,. FUNCT N SATISFACTORY. ,% , ,--
DATE. g ... Inspector........ - ,_
7.1.....-.-..
THE COMMONWEALTH OF MASSACHUSETTS
c BOARD OF HEALTH -
No........ 7%-.: ,...............'.... FEE::'....
Disposal Works TUoustrnrtinn Vrrmit
Permission is hereby granted f_�:':...........:::.:. ..............•-'......•-•-•-.....•---........••-•••••-•-.........•.•-••-...........---...........
to Construct ( ~) or Repair ( ) an Individual Sewage Disposal System
at No
:.......... = .......C. = --
`� Street _ _ -�
as shown on the application for Disposal Works Construction Permit No......_.! ......... Dated..........................................
�/.
Board of Health
DATE----- ....................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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