HomeMy WebLinkAbout0009 HAWTHORNE AVENUE - Health 4 Hat�fhorne Awc•, J4�r►n�.r
Faso�eoy —_- . _ _ �_ -\
FAX & STAPLER MANUALS '
M
TOWN OF BARNSTABLE
LOCATION hf91a 7-1-id a- '✓E ��/l SEWAGE #
VILLAGE ASSESSOR'S MAP.. LOT
INSTALLER'S NAME & PHONE NO. � �!�l.�S� S
A
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 3 4�� Il YS (size) /d X
NO. OF BEDROOMS
3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNERS
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No -�
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Al
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Touutrur#iu Permit
.Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: i
Location-Address or Lot No.
......................--..........-.f•S/'►�Il o✓/f - --------------------------- -----------------------------
. ........_.. .... ... .
Owner Address
W ...................4.4-.W....---..( Q.r .S.T----........----•------------ ....................................... .........-----.............-...............
Installer Address
PQ
4 Type of Building Size Lot----------------------------Sq. feel
a Dwelling—No. of Bedrooms.......... ............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................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........................
----------------------------------••-----------------------•---.....-----------------------------............................................................
0 Description of Soil........................................................................................................................................................................
x
w
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------• ------------.....
0 Nature of Repairs or Alterations—Answer when applicable-.-- IV-d-Q---T�r........*`._.-.3_.G_'Q_ C.....................
-•---------------------------------------------------------------------------------------------------•••--.....-••••••--••••••••--•-•-••--•••---••--•-••-•--•----•---••-----•-------•--............•---
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 Complian e has been issued by the b r.d..i o heal
Signed --- �
Dace
Application Approved By21—
Dare
Application Disapproved for the following reasons- -------------------------------------------------- ---------------------- ......................................................
-------------------------------------------------------------------------------------------------------........................................... ............................................ -----...---------...------------------
Dace
Permit No. .:..... .....d.-- ,
--------------------------- Issued ......................................-............--------- -----
Dare
�'..... .��...._'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for Disposal Works Tonstrurtion- rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
Location-Address or Lot No.
v�iS S/tij izr �✓r+/
Owner Address
Installer Address
d feet Type of Building � Size Lot___________________________S q..
aDwelling—No. of Bedrooms.._..._.._3............................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building .........................•.. No. of persons............................ Showers ( ) — Cafeteria ( )
Q' 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........................................
4
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gzl Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ••••--•----------------•----••-------••------------------...--•-----...---...---...--•---------••--------••••-••-------•--•------•--•----••--••---• .
O �►•-
Description of Soil.............................................................................................................................................................C-----�V
V .........................................................•-••--•••----•-•-----------•......•••--••-•._....----------------------...---•-•----•--•--•----•••-•---•-----•-••----•----...--••--------•--••-
W
U Nature of Repairs or Alterations—Answer when applicable_... ST•--_--_•r,-_--, ••G .... /%Y S___._-_--.,
....................................•.................................................................................................................................................................
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�.�� `......------��ti!Z �
Application Approved By ...............
- �........................................................................ ............ Date
Application Disapproved for the ollowing reasons- --- ----------------------------------------------------------------------------------- -------------------
---------------------------------------- -- -----------------------------------------------------------------------------------------------------------------------------------------.................... ....................-- --------------
n' 7 Date
Permit No. ------ -�� -- �`�...--..`.`�.............
-- Issued ........... ............................ ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH t
TOWN OF BARNSTABLE
U ez#ifira a of Glom Iinure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or'Repaired ( )
------------- ------------------------------------------------------ --------------------------- -----------------------------------
-.-,0 ----- Installer
at ...... ... <� /A....... .. ........��t ti-7:....------------------......//Y-'9-N.%'..!-J....... . ...4---7-----------------------------------...------....
has been installed in accordance with the provisions of TITLE 5 0, fghe State Environmental Code as described in
the application for Disposal Works Construction Permit ...p`Z-7..-..--.--.. dated ---./../-------------------...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM/ ill FUNCTION SATISFACTORY.
DATE Inspector ..----- - -.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� TOWN OF BARNSTABLE
No....: r .it"... FEE.,-.. ..... ..
Disposal Works Tunstrir#ilan 'prrmit
Permission is hereby granted !-G•N-----------•------------------------------......
-...............
-........
..........
..---------
to Construct ( ) or Repair (�)an Individual Sewage Disposal System
at No.................. _..� .Q �c. 7` N �_ ..' _<`.................... �`�_ w R 7?
•-----------•-----...
Street Q
as shown on the application for Disposal Works Construction Permit No./.. �Dated.._..•....................................
.................................... .3.....-••----•--•--•-........----.....----•-•---.......-
DATE. ��� � ......... Board of Health
-.� ••-•------•.----•---•-------
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS