HomeMy WebLinkAbout0187 LOCUST STREET - Health 187rt Locust Street-I y
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—LOCAT.IO�N- _ .___ w __ 5EW AC4E_PERMIT UP.
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—BUILDER 5__1J.A-►.�IE_�__AD_DR.ESS-.. ------ --- ----
-- _DATE -PERMI7_15SUED --
_ _—D-ATE COMP-LI &MCE _ISSUED - _
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W11' ' . Town of BaI'II$table. Health Inspector
oFCHe a ram, Office Hours ti RegulatoryQ Services 8�0-
9:30
Thomas F.Geiler,Director 1:00—2:00
* SAMSMBU.
Public Health Division
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• Thomas McKean,Director 3/0 -
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200 Main Street,Hyannis,MA 02601
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Office: 508-862-4644 .
Fax.:- -790-6304
AMNESTY PROGRAM APPLICANT-SEPTIC QUESTIONNAIRE;
1. General Information: Size of Property: po-t P,
! 9/ ,�oCa�% V% fJ 1��f Mapl Parer
Address:
Name: N6 1.Jeco4N Phone#: 7S v2-0 7 Z/
2a. How many bedrooms exist at your property now? V
2b. Are you planning to add any bedrooms? /V U If es how man ?
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2c. How many bedrooms total are proposed at this property(including the amnesty unit)?
2d. Please include a copy of the.floor plans for the entire property showing the existing
rooms in the home plus the proposed amnesty apartment and/or addition. Please label .
each room clearly on the plans.
3. Is the dwelling connected to public sewer? YES or NO
�` �I`fthe-dwenig�ls connected�to pubhc.�sewer,slapwgueslions�#4 through.#9`bE�lnw_' -� - ,
4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?
5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?
6. Is a disposal works construction permit on file? YES or NO
6a. If yes,how many bedrooms were approved according to this permit? Bedrooms.
7. Were any building permits obtained for construction of additional bedrooms? YES or NO
.8. Is there an engineered septic system plan.on file at the Health Division? YES or NO
9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
----------- w�---- ------------- ---- ----------------------------- --w-- ----------------------
FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: Date: OS
O;1health/wpfil es/amnestyapp
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No.. ..... Fps .....................
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD H EA T
OF........... ..... ..-.. - y...........
....-
Application is hereby made for a Permit to Construct ( ) or Repair (-Ar—an Individual Sewage Disposal
system t
- --------- ----- -
Location•A r ss a�� got o.
e ( Address
W
nstaller Address
d Type of Building Size Lot____________________________Sq. feet
U Dwelling'—No. of Bedrooms.-__------------ _-_______Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of, Building :_______________________ __ No. ,of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures _
--••- -•--• -------- •------ - --------•--••------------•--------------
W Design Flow_ ______________ ________ Mons per person per day. Total daily flow.._.._.._._.________._ _-._-_.__gallons.
--
01 Septic Tank z Liquid capacity .x allons '- Length--------_------ 'Vidth- ------- .__.. Diameter____-. Depth----------------
Disposal Trench— o._:____ _ th._._ al jfKth-------------------- Total leaching area--------------____.sq. ft.
Seepage Pit No.. __ _. _ I t ____ _______ epth below inlet____________________ Total leaching area-------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY------- ------- ---------------------------------------------------------- Date__-----------------------------------
Test Pit No. L__-------------minutes per inch Depth of "Pest Pit_..__._.____________ Depth to ground water.._-__--____-_--_-__-.
f14 Test Pit No. 2___e__-.________minutes per inch Depth of Test Pit____________________ Depth to ground water__.______-____----_---.
a,
0 Description of Soil--------------------•--•--=--••--•---•-•---•-•--•-•----•-------•--•---------------- -------------------- ---:---- --•-------•----•------------•--•---•---------------
W ____________
yP.
----------------------------- .. ........:.- - '---------- ------ ------- ---40-;_ _ _
U Nature of Repairs or Alterations—Answer when applicable_- ------ -- (��� - ------ ----- --------- .
- s-
Agreement
The undersigned agrees to install the aforedescrtbelf Individual Sewage Disposal System in accordance with
the provisions of Article XI of;the State Sanitary Code jThe undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued'by th board o health.
F
S, d---- __ - __�__________ ____________ ______________
- Date__
Application Approved B
Date
Application Disapproved for the following reasons:.....------------------------------------------------------------•----_______-•--•----------•-----------------
__------•-------•--•------------------------------------------•-•--------------•--•----------___---------------------•-----•-------•••--•-----------------•--•-••-----------•-----------•---• -•--•-----
�/ Date
PermitNo............................. ...................... Issued_ ......... -----------------
Date
No................n....... FED.. ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
.�pplirtttion -fur Bi,4puiittl Work.5 Towitrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( t) an Individual Sewage Disposal
System at:
Location-Address „nor„Lot No.
_,,,,owner / J Address
Installer Address
dType of Building -- Size Lot............................Sq. feet
Dwelling—No. of Bedrooms---------------..............•.__•_-_--.-__-Expansion Attic ( ) Garbage Grinder ( )
a4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
da Other fixtures f------—--------------------- - -
W Design Flow........................................._.gallons per person per day. Total daily flow--_-___---•-_-- 7_..._________= .-.--gallons.
WSeptic Tank—'Liquid capacity f-___I-_gallons Length................ Width------.......... Diameter_-.__..__-_-._ Depth---.----_-.-----
x Disposal Trench—No. ..............Z,__.Width--------------------- Total Length-------------------- Total leaching area....................sq. ft.
/ ____`'Diameter--__-___.__:j__"_'De th below inlet.................... Total leaching area.._-___-._.-.__--_sc ft.
I � Seepage Pit No..!_._________ P g t 1• -
Z Other Distribution box ( ) Dosing tank ( )
'- Percolation Test Results Performed b Date-.----.•_______________________________.
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.---.-_---.---..-..._.
(i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water...---------------------
-----------------------------------------------------------------------------------------------------------------------------•---------._--"-------••-•----------•-------------------------••-------------•---------------------".-----.--•---•---..-----
0 Description of Soil-------------•---------•-------•--------------------------------•------------------------------------------ ---------------------•--•---"--------------
UNature of Repairs or Alterations—Answer when applicable._.____r-._.._..11 ------_------------------ `__--_._-_-_--.------..-.._.--.____"-_.....
---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------
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.
Signed...................m.............=-------
Date
Application Approved BY f E. -` ------- -_�- . .....................................-
/
•
Date
Application Disapproved for the following reasons:................................................................................................................
•--•--•-•--••----•----...--•--------------•-••---....------.._..._•------------------'-'---••-••---................... ---------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFI HEALTH
Y. .
..f..r........:........i.......OF...........1�,,.%°":....':.. ..........................................
Trrtif irate of f"omplittttrr
THIS IS TO' CERTIFY, That the Individual Sewage Disposal System constructed ( ) -or Repaired
r Installer
has been installed in accordance with the provisions of Artticlt XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No__'_-j__..___:__�"_-h_______ dated_..`:=_'_.J..."'..... ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------------------------------------------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFF HEALTH
..... ........................OF.............
No.............--•- ..... FEE---=.................
i� u�ttl uxk ClIvtciitrurtion Permit
Permission is hereby granted_... __.%-_-_-- _______
to Construct ( ) or1Repair (t`)man Individual Sewage Disposal System • f
at No.. 1t : t
Street _•
r
as shown on the application for Disposal Works Construction Permit No.--................. Dated...`"-._."__./.....__._..._..__........r
1, . x/`
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✓ Board of Health }
DATE-------------------------h..--- -----...------------------------=-------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS