HomeMy WebLinkAbout0041 OLD SCHOOL HOUSE RD - Health T) dID ovl h dam, ed
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Lot 3 TOWN OF BARNSTABLE
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LOCATION '411 04 Sc-bolko'd C, SEWAGE #
VILLAGE �✓ �yp a�q a �,���� ASSESSOR'S MAP & LOT
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY get l,
LEACHING FACILITY:(type). - (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER n"• yC`tilt4 4
DATE PERMIT ISSUED: /
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS ,
BOARD E/ ®TRH
"' ........OF..... . . .......
App iration for Uhipiial Works Tnnfitrurtion. 11rrunit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 2Art .40
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, :. ij �Locati = d ress or Lot
._1 -•._.� ..:.. ••....."-._...... ....d._ ........................... ........_....._.._.__......_..._..______...--
...
O�pvner ,�y
Address
W � _ ° ...
U Type of Buildi �gf� nstatter Ad
dress
...........................Sq. feet
Dwelling Z/No. of Bedrooms------------ ...:....................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ________-__-______________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures ......................................................---•--------•-••---------------------------••---•- -------
W Design Flow..................... ..� __..___. llons per person per day. Total daily flow._........,, j! a'_, ......._...gallons.
WSeptic Tank -Liquid capacityLf -__..gallons Length................ Width.__.._._._._.. _ Diameter---------------- Depth_--___------_._
x Disposal Trench—No..................... Width............ 1 Le h....__ Total leaching area....................sq. ft.
r -
Seepage Pit No.-----___/__-_----_ Diameter `" .. e o ` iS®1 ,.. Total leaching area__________________sq. ft.
Other Distribution box Dosing tank
Z ( ) g ( )
aPercolation Test Results Performed by.......................................................................... Date....................................
Test Pit No. 1.................minutes per inch Depth of Test Pit.................... Depth to ground water"_____-__-_____-._:-_-
G4 Test Pit No. 2................minutes per inch Depth of Test Pit......i-I
------ Depth to ground water---------------------_-:
a
------------------------------------------------------------------•----.
. D Description of Soil---------------------------------- ''` - �----------------------------------------------------------------------
x
U_ --------------••-•--------•--••--•------•-•-------- ------------- ---------•-----------•-•---------- ---------=---------------------
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 YI of the State Sanitary ode—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued byh board of ealth.
._
Signed ••-- .--------.•. .....................................................
----------------
� Date
Application Approved By....... ••• ..- r 4
a
Application Disapproved for the f ollozwing reasons:--------------------------------------•-------- ------......................-------...............................
..-------•------------------------------"------------------------•--------.....-•------•--••-------------
Date
PermitNo......................................................... Issued. M ................
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THE COMMONWEALTH OF,MASSACHUSETTS
BOARD OF HEALTH
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Teti€iratr of Tanaliiiaurr
J(,TW IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( � or Repaired ( )
by / an S.�r" �.�� �'"' ��.. r�.��S _�
.J ....... ......... _.. ?.n _
54
Installer
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has been installed in accordance with the pr€� isions of Article I of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._____Ca.
. ..................... dated.......... _"_ .:_ :^..._ :..._..
�.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE.CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WIL - FUNCTION SATISFACTORY.
DATE °gi' � ` ----------------•-------. Inspector ,;r .- .� ..'
k: ��.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEALTH
60
No.. -- ._-- -
i rn � nrk� Cnnnstrur#inn rnmit
Permission.is hereby granted----- -- . ....... �I�''`... .....
to Construct ( 'Repair ( ) an Individual. Sewage Disposal S stem ,
at No..-_..I �-_... _. s���?� �:...J��_ "r"� ��r� � �_� � -._'f-•! ---------------- -
f ------•----------
Streeter
as-shown on the applic tion for Disposal Works Construction P o. ..�, d___-_ :_• 1. -_ •-••.-.
r -------- - ---
"� Board of Hea th
DATE..... ---- --- --------l-.- _
FORM 1255 H BBS & WARREN. INC.. PUBLISHERS
No. --------------- F��_ ................_
THE COMMONWEALTH OF MASSACHUSETTS
E®ARD F HEAD
....OF,....... -- -.. . ....
AVp iration for Dispoottl Marko Tonfitrurtion Vamil
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at ............
J . . . = d (mot/ '
Locatio d ess or Lot o.
----• •. .. ........ - ""A............................................................................................
W O n�er� A r Address
.r: - --• •---- ...-•-----•• ----�-L- ---------•-------••-- ----- -----------------•---------....
nstaller � Address
Q Type of Buildin Size Lot.:a_______________________•_Sq. feet
U Dwelling-?1Vo. of Bedrooms:.......... .. ................... ....Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Type of Building ... No. of persons............................ Showers —_Cafeteria
a' Other fixtures
- - ---------------------------------------------------------------------------
W Design Flow....................�..0-._.-.. o}}��s��pe�..�er n per day. Total daily flow____.___-. gallons.
WSeptic Tank I Liquid capacit _ ga IZPSX�enp________________ Width --------- . Diameter______._.___._- Depth__.__________...
x Disposal Trench—N . .............. Width..._. _______�.. L '...... _ Total leaching area.... sq. ft.
Seepage Pit No._________ Diameter .. e .............. ... Total leaching area`,' f_�.�_____sq. ft.
Z Other Distribution box ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_.-___.____-.-_-______-
GTq Test Pit No. 2................minutes per inch Depth of 11
Pit_._........_ ___... Depth to ground water_-----_____________._...
-----------••--•---------------=•-------- •.... ------• . --- .i........••---•-------------•-•-•-•----------------•---•--•-----•----
Description of Soil................................................... 2 . ----......
x
UW ----------------------------------- •-••--------------•--- -- ------------------ ------- --
Nature of Repairs r Alter ons—Answer w 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 de—The dersigned further agrees not to place the system in
operation until a Certificate of Compliance ha b issued by th board of ealth.
Sie ---• .------•---•--- ---- `--•-------------•--••-----------•-- -••-- ..•.....
Application Approved B Date
PP PP Y L �i � t
Appli tion Dis ro ed for the follo -ing reasons:_-r--.. /_. _„� J
Date
PermitNo............ f-------------- --`-� ��Z( Issued. - --��- �.�•5
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