HomeMy WebLinkAbout0381 MAIN STREET (COTUIT) - Health Tyr � "rtt� ,
I
TOWN OF BA:RNSTABLE
LOCATION�'4 v: D SEWAGE #
VILLAGE_lCD r U ASSESSOR'S MAP & LiT
INSTALLER'S NAME & PHONE NO. bVn
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)_P C �T_
r ,
NO. OF BEDROOMS 3 PRIVATE WELL OR BLIC W� L�
BUILDER OR OWNER y',�G1ls.
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED___
VARIANCE GRANTED: Yes No _ _��
�y
665T�- d VD
.t
No._............ ....... Fps.....
THE COMMONWEALTH OF MASSACHUSETTS'
.. ;. BOARD O.F 'HEALTH
f
Appliratigtt for Disposal Works. Tonstrurtiuri rumit
Application is hereby made for a,Permit to Construct (: ) or Repair F•---�'an Individual Sewage Disposal
System at: ,
............� �........f.�!1: :� -----= ........... ........•••-..�r� ry - ....................................................
Locat•on-.Address or Lot No.
. .... :Sd ... .6V —------------
..................
.-^...........................
Owner Address
_ o q
--------------
'Installer r Address
Type of Building Size Lot..........................Sq. feet
Dwelling—No. of Bedrooms ....._-�...._._..........................Expansion Attic ( ) Garbage Grinder ( )
Other,—Type*of, Building
a yp g ............................ No. of persons--••:...................... Showers ( ) •— Cafeteria ( .
r Other-fixtures '
d .............
Design Flow....:._ ...........................gallons per person per day. Total daily flow....._._....._......._..............gallons.
-Septic Tank—Liquid; 'capacity............gallons Length................ Width................ Diameter................. Depth................
x ' Disposal'•Trench=No...................... Width............ .:.... Total Length.................... Total leaching area.....................sq. ft.
3 Seepage Pit.No.......J:....._.p_ Diameter..../C..... Depth below inlet....
�4............Total leaching area.................sq. ft.
Z Other-Distribution box (; ) Dosing tank ( )
Percolation Test Results Performed by:............................................................................... bate..................
,..... '
Test Pit No. I................mmutes per inch Depth of Test Pit..................... Depth rto ground water.........................
Test Pit No. 2...........:....minutes per inch Depth of Test Pit._._..........__.--.Depth to ground water...............
ODescription of Soil... ....--••------ •-•........:.. ................... ..-------•--....... '----------•-......--.....----....................._................--•
W ....._....• .......--••....... . .- . •-------------•--.........----•-•............. .. --•--- ...............------....-•--•---..._...----...............--•-•...........--
= --------------------------•'-------------•- -------------------------------------
••--------..--•---•---......... -------------------
U Nature of Repairs of Alterations—Answer when applicable:_-_� 'Q......O.j? �-:...arc--��..:�1`� .. .........
' :..' Q: . =z S �Ca �--.............................=.......................=.................................................
Agreement
The undersigned agrees,to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITHE' S of the State'Sanitary Code—-The•uridersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued'by.tli board of,health:
Signed.'.
-... .... .... _ 11 i
Application Approved`BY /a""`-_ "= _..._.__ 4
Application Disapproved for the following reason : --'-••-•---------•......----•--•--••--•--•-••--••--••----•----•-••--•-•-......-----••-•---•--••..............
. ..
4 ................•--. ...............................................................................................................................
. r .. + Date '
Permit No..• :.. •= Issued..:.
# Date
No. 01
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................
�
OF...... _.-! ! .{!®b�................................
Appliratinn for Disposal Works Tonstrurtiun thrmit
Application is hereby made for a Permit to Construct ( ) or Repair (----van Individual Sewage Disposal
System at:
...........:3?�........E Z- =• �- ......................... ........................................................
.. ._.
Location-Address or Lot No.
_!1 s.. ........... •-----------------! ............................................................
Owner Address
0
Wa .............. ........ "�...=...........� -5`P��°� r�•- .............. ................ .'��^ '.f ..... ......
Installer Address
Type of Building Size Lot............................Sq. feet`
Dwelling—No. of Bedrooms.......-�..............................Expansion Attic ( ) Garbage Grinder ( )
`k Other—T e of Building _
dOther fixtures . -•------•----•-----------------No---of persons:-----------•---:------ ---Showers (•�) Cafeteria
Design Flow...........�......................gallons per person per day. Total daily flow___.3.3• ...........gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter____........_._. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No........J.......... Diameter....I .___.._. Depth below inlet....tr9............ Total.leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed by....................................................................•_.... Date..._...
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------------------------------
•....
----•-------......
----------------------------
.....
.---
--.---•----------------
---------
.--•--.--.....
-----------
-........
0
Descriptionof Soil......................•------....................------.......------------.....----•---------•--•--•-------:.....--•---.......------------.............................
x •--•••-----------------••-'-----•'---------.........-••------'-•---------.......-•----------........--•-------•---------'------'-•'---•--------•-•-:..---------------•----........••. --------...:...
U Nature of Repairs or Alterations—Answer when applicable......4 0 Qo w ..._ ..............
........... � •....r'to c:C�l%aL -...----------•-•--••-•----•----------------'-•--...------•----..........................................
y Agreement:
The undersigned agrees to inst'all,the aforedescribed Individual Sewage'Disposal System in accordance with
the provisions of,iI.LE ,5 of the State Sanitary Code—:The urider8igned furhher agrees riot to;place`the system,in
f. operation!until a'Certificate of-Compliance has been issuedby the board of Health;
' _Signed.igned
Application Approved By-- ��� .. =.,.... _.,..._.... ---••-•-• ...Z..-:-
ate b
Application Disapproved for the following reason's�-•-........................................................................................................
- Q Date
-t--�Permit No.._-`•.:, ! ............................ Issued...........
-----------................................
Date
— .-- ——— ------ ———————— —————————— -.. 7---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
\.:C` / /. /`.........OF .VIA.hST�4 .�.141;':�Z....................
Trrtifiratr of f omplianre
THIS IS TO-CERTIFY, That Pe Individual Sewage Disposal System constructed ( ) or Repaired (�)�
by................. ( `....1.::,a -•-•�.r•. ..
Insta(er
at............:�`�..�.. 14• = a - f ��� '�
has been installed in accordance with the provisions of TIT n 5 of lie State Sanitary Code as scribed_in the
application for Disposal Works Construction Permit No• - .. dated---.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
d ,
DATE.................... I -� -----------: Inspector..-r-------•-- .. .. - ..--•............. � .:..----------•-----...-----•-•-------..............
.�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
2—
0
No.... FEE.... .........•••......
t �attl Works �nntrnrtinn rranit
Permission Is hereby granted.......�OrA-----.•-------....... !----- ....................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No. ll1E..• .! � ..._...--• - - .Street �/ r '/
as shown on the application for Disposal Works Construction�Pe mil Not>�...._, -, ated..A.t1.-/�`����.... In
. ...•-•---.. - ------ . �
.
_ Boar �Eieaith \
DATE.............�------.�-;. �w-----------------------------------...