HomeMy WebLinkAbout0012 WASHINGTON AVE EXT. - Health TOWN OF B.ARNSTABLE
LOCATION )�� 0,-S t�(6yc,Zo u.cAV SEWAGE # �� �
VILLAGE 0./(4y ASSESSOR'S MAP LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY � G 0
oo ,g4
LEACHING FACILITY:(type) 9 PAe�(,5 � 3f�� (size)
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WA
BUILDER OR OWNER eru.vt,-(- e ST hV'E O�ff
DATE PERMIT ISSUED: (p-C -- ' f4 7
DATE .COLiPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No.52 3 Fss....aG-.�—
THE COMMONWEALTH OF MASSACHUSETTS
-BOARD OF HEALTH
: y .............d W..!..........OF... �A.-��� .................................• F
Appl ratign for Disposal Works Tonstrnrtiun rnmit
r Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: LL
.... ..1 t � inn"......----• a�:{."X !:S:z�'...............-.......
Ln_ s ......... ._..
or Lot No.
..`� .. sS'S :�? :k`5..........................:.... ,5.. :�!1!!i:'�.---•--••---- -.........._.._..........._...---.:
ress
a -` ................. ......... ..... �.ws:: ............................................
Installer Address
Type of Building Size Lot... _..:____. ..___.Sq• feet
U ._...--.....Ex Expansion Attic Garbage Grinder-.,., Dwelling—No. of Bedrooms......... ,.. p (. ) g (. )
Other—Type T e of Building
p4 yp g ............................ No. of persons............................ Showers ( ) — Cafeteria {w )
a -
Other fixtures -•-•-•----------------------••-•-••• •"•-••. ..... ._-•--•-••-••-_•-• 1 •• -•------......_.
WW Design Flow... _. ......................gallons per person per day. Total daily flow.. c.I_v.C>..................gallons.
a Septic Tank-Liquid capacityt.WDgallons Length ..ti1........ Width...(Z......... Diameter............... Depth.;..............
Disposal Trench-No .__._:1............. Width..... Total Length..._._1D.........Total leaching area ...................sq. ft.
3 Seepage Pit No_.......:.......... Diameter..................... Depth below inlet......._......._..... Total leaching area...................sq. ft.' '
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY........................................--:_.____-•_______•___...__Y:------ Date........................................
Test Pit' No. .1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
z
a .....-•-..._.. -•-•••••••........... ....•••-•••---••••-•••-••---•-•-•_. .......................................................................
ODescription of Soil......................................................................................................................................---..........-•-......::........-•-
x -
U Nature of Repairs or Alterations .Answer whe` appli .vs.0.0.
WN.� .- ° ,.......... ........ c�_'_-.._ �- .w e...._S .�c u� '�. _..
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T1'LMe 5 of the State Sanitary Code—,The under further agre s not to place the system m
operation until a Certificate of Complia sued by the b r lealt .
Signed -•-=---
. - . _..
Date
Application Approved By........... % ._.. ........................................
Date
Application Disapproved for the following reasons:_...-•--••----••.......................•------------•--•----•--......-•--•--•-•---•--•--•--••-•••-•--.....«««
.............................................................. --••••--••-----•-•....•---••--• ••............. .....--------
Date .
Permit No...... .... Issued........................................... ...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
—C`/�V...�` -.......OF.......�>.,,...��!:/..!!....`.,`-�� (��-1�...................................... . . .......
_-- - utt#iun fiar= n tt1- arks Tonstrur#inn ramit
Application is hereby made for a)Permit to Construct ( ) or Repair ( t-)aii Individual Sewage Disposal
System at
.-.......» iJiu.V� �� ^c�v;��1_ . �%...1.. 1 U '... ;Z`.�'y�......... 1.��l»rn._,:�c (.....................................»...............
-rf- Location Address_--- - ` �} or Lot No.
{— —Uwner - - Address
:.:............ r.................. ...........................
Installen' j 1 Address
Type of Building � LJ Size Lot............................Sq. ,feet
Dwelling—No. of Bedrooms.�...._f---------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _----------------------- No, of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --•-••----••------•-•-•...-•---•.................................••--••-....... --•---•----............l....................._....----•-••-•-...----
WW Design Flow........a.. � ...................gallons per person per day. Total daily flow.._...L .. .�2..................gallons.
WSeptic Tank—Liquid;ca.pacityJ5022gallons Length.-A.!........ Width...k a..._..... Diameter................ Depth................
x Disposal Trench—No.__.:J.............•Width'-, ........ Total Length....k.h..1....... Total leaching area...................sq. ft.
3 Seepage Pit'No..._--..._._._..j_.. Diameter!......_`........ Depth below inlet.................... Total leaching area.................sq. ft.
Z Other•Distribution box ( ) Dosing tank ( )
a Percolation Test Results 1Performed bY.......................................................................... Date........................................
,.a Test Pit No: 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No..: .......:..minutes per inch Depth of Test Pit.................... Depth to ground water............._..........
x .........................................•---------..........•••--............-•-• .......................................................................
ODescription of Soil.........................................................................................................................................................................
r
.............• ---••---••••--------••-•-------••----•----•-•---•••...•--•--•-••--•----------•. ....-••-•--• --••--......---------..--..........--•---------•--•--..._-•------..............................---•---
U Nature of Repairs or Alterations—Answer when/n applicable..._. /'4.\.S`t_!P_. ..........1.�./JZ�...,_,S�F.!Q?.1C 1� -
tn'1 C,�= �1.0}r. 3._..�..Ts.� I...G�l-lq..l l r.��..�.......r�r.a. �' ''f'��� �`� ��/1.�.6i V�cQr ry �
Agreement: r 4 �..'J�.........
The undersigned agrees to install the, aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITA IL 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
liealth\
Signed. ..... `�a ...... `? .. • - " �;
c s Date
Application Approved BY .........% ---------------------------=--- ..................................
Date
Application Disapproved for the following reasons:---•---•------•........................................................-..................................---
......................•-••••••-•-•-•-• •--••--••----••••-••..._.......-••••-......•-•••••...•-•...................._...•----•---- •--...•-.--- ............_
Date
Permit No...... ? c� ..........._...... Issued.............. '..................
Date r
}
THE COMMONWEALTH OF MASSACHUSETTS
� Nl�tr / BOARD OF HEALTH
!/ -T.C��,v ..........OF.....> . ..V..S � :........................
f9rrtif irttte of Tontplittnre
i/ THIS IS TO CERTIFY„ That the Individual Sewage Disposal System constructed ( ) or Repaired (�--)--�
by...................X ---••-••--l'1 u ,. ! s---------------•--•... -------•-.........-••-••-•-•-•--....--•---•-----....._...........•-•-••...----•---....._._.._..._
Installer
at...... 1 ------_tl&l..~P------. C��c�I'_�..... -4-``/�',u 5
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... 4.._._....._. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
\
DATE._..._..--•••--_--•------------- =-•---•-•-......--+-•---•--._........... Inspector....................................................................................
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
TU W ..-.....OF.......�..x.. .ti.�ti s`�.,4
............. .............
oa2
Disposal Works Tonstrttrtion 11erntit
Permission is hereby granted...........
--_-___._.-- "' .� •-•---•--------•--....-•..................................................
to Construct 1(�-)� or Repair ( (-�)a`n LIndividual Sewage(/Disposal System
atNo.............A- L ►vA-e/l�� G R A.�A._v_ _//. ._:.._.__^n..!xrn...........c !�__ ,.!.._.._...... .\/( !!. 6.�.v�.................
r Street ����� �.-.
as shown on the application for Disposal Works Construction Permit No_________________ ted..........................................
.......................
Z r 0 Board of Health
DATE................................................................................