HomeMy WebLinkAbout0025 GROVE STREET - Health (2) 75 Grave Street
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di_rVv!3a1 lVark.6 TonBtrurtion Permit
Application is hereby made for a Per t Construct ( ) or Repair,, an Individual Sewage Disposal
System at: 7
rp �................... -----
^ J -•Location•Are
� or Lot No-
....=.Se�.�. .---------•-•-•-...... -`C- ------------ -----
wner \\ •
,.a ••-•-•.... �-.... ---"----------------------------- --l` ................. :---------- ........
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms_____________3_________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—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.
3 Seepage Pit No--------------------- Diameter--------------...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
aTest Pit No. 1--------_.......minutes per inch Depth of Test Pit-------------------- Depth to ground water-..-_._.__._____-._-._..
G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04
0 Description of Soil__________________ j
U __
W .._._.....-•--- -------------------------------------------•------------•-------•-•-•••-•---------------•----------------•--••-------•-•- -------- ........__...
x N ure of Re airs or Alterations—Answer when applicable................. .. �_ _ '
U P PP t ---- (....� ••(,� �..
,I =•... _W- =E,-'mac�"'k 4---.._...._.__t_ .. C�J �'Y ®. ....
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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 Compli ce as een issued by the board o health.
•
Signed ...' ............. ..L.. A.9............
.��.
Application Approved By . .. .........................................._.._........._-......------._.----------------------------------------------- -l -------------------------
Date' ' 4f
Application Disapproved for the following reasons: ......... .... . ....................................................................._
....................... ......... .. .a,.�. W..� ..-
Date
Permit No. _ -j.......° ............. Issued ............
. - -
- Dace
- - - - —————— —�_�J
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parce t 41 ( O Fss ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
-.
Appliratiun for Biupuuttl Workii Tontitrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:4r-
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5 .
Location AddrC or Lot No.
-------------------- --------------------------•---------•-----....-------•-----------•---.............................
Owner dd�ress
-----------------------------------------------------------------------------•--
Installer Address
Type of Building Size Lot............................Sq. feet
�-t Dwelling—No. of Bedrooms--__-__-_--- -------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------------- ----------------------------------------•-------------------.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitv------------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 ( )
�t Percolation Test Results Performed by.......................................................................... Date......................................
W
a Test Pit No. L...............minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 — --- ------------ •-------------------------------------------------------------------------------
------------•-------------------•------------------.--.--
0 Description of Soil.................. ....
V -------------------------------------------------- ..------.. •----------------------------------------•----------------------------•----•----------•-------•---. ---------•-------
W
x ------ - --- - - ------- -------- ---------------- ----------------- - ----- - ------- -----------------
U Nature of Repairs or Alterations—Answer when applicable._...___...._'-f. _�_._.__.... .........
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 Compli nce�Ias been issued by the board o health.
Signed ................................. .... . ... ___
Application Approved By -----------------------------= .^. 7...... ...
Date
Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------
. ..... . ...... .... ... ....................................................... ... ......... .....................................
............. A ...�......
�j— Q..-... Dace
Permit No. ' T-✓.... b.................... Issued ........(....��. / C�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#tftra e of Compliance
TH/VS TO C RTIFY, TI at the Individual Sewage Disposal System constructed ( ) or Repaired
by ........... .. 4 -� -ram..--------�? _�,-�.r:-- .�-----5-=
Insruller
at -------------------7.S--..-----C .. .........- � -----------�f�� �� 1,41A- -
has been installed in accordance with the provisions of TITI.E5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. - ... �.��z��� - dated ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...--/ .......... m� ....... .. .....- Inspectorr�.-...- / ?..;! .-:- i/-
--------- ----------------------------- ----------------------------------
C)`�o THE COMMONWEALTH OF MASSACHUSETTS
1 �` BOARD OF HEALTH
TOWN OF BARNSTABLE0,
No;....� ................ FEE........................
RoVosai- ork,q Tanotnulion VarAit
Permission is hereby granted------ _'�.�. '` .__... _?^. . ..... c�Ls
..............................................
to Construct ( ) or Repair ( an Individual ewage Disposal sSystem
at No... 7 �� 'a,r o v-�. -.... �-- • !1` -- = ----- .......................................
Street G� Q [[
as shown on the application for Disposal Works Construction Permit Nam_ ` Dated__, _�-�.�./-_�..._...1.
---- . � , --......
............................... Board of Health
DATE------ ----------------------------------------
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
TOWN OF BAR STABLE
LOCATION , SEWAGE #���
VILLAGE (� ASSESSOR'S MAP & LOT ML-)-
INSTALLER'S NAME & PHONE NO Cl
SEPTIC TANK CAPACITY lJ b o
Lam fc -�
LEACHING FACILITY:(type) Velt
(size) "�`T '$4ow<
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR`OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: I L4
VARIANCE GRANTED: Yes No
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