HomeMy WebLinkAbout0651 MAIN STREET (COTUIT) - Health C�l ���� ��c�ti�
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TOWN OF BAR`NSTABLE
LOCATION i�_/ � .v SJ- SEWAGE # � c;
VILLAGE �� 7'� ASSESSOR'S MAP Cz LOT d34.- 6Z
INSTALLER'S NAME & PHONE NO. /e�,- J S I ��
SEPTIC TANK CAPACITY / -S 0 y ��
LEACHING FACILITY:(type) A�y l�j T (size lae aGh%
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BAY R OWNER �y9�-&.s e),.I./
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 15 -air
4
VARIANCE GRANTED: Yes No
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No. ...'-...�...... Fps... ...._.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
. ..n/.............OF......./ g 2 ..
Appliration for llhiposal Works Tomitrnrivan Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
-•• -5 f �.�....�..-•.....-7-•----------•d•7�v -. -••••---...•--...��...�.1._........---.._...--••-•-••---•...--•-------•--•----•---•----••-
Locat' Address -•...........................•---•-----...or Lot No.
1c�Z �c�r J�cr�son/
----- -----
Owner Address
..... Gf� �6 ti ST
Installer Address
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 ( )
dOther 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.
Seepage Pit No-_------------------ Diameter---................. Depth below inlet.................... 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..-.-.--.-------------..
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...---.............---..
P4 •---•----••--•-•---------------------•--•-•.....•-•-••••••.........-•••••......---•••-••••-••-------.........................................................
0 Description of Soil........................................................................................................................................................................
U ----•-----••----•-•----•--•--------•--••-••-••-•-••-•••••••••--••-•••-•-----•...--••••------••••-••••-•••••••------•-•••--••--•-•---------••--.....•---•---•--••-•--••--••------------------•......-----
W
x ----------------------------------•---------------------------------------------------.....-----------.............................................. ----------
U Nature of Repairs or Alterations—Answer when applicable... v
•-------------------------------------------------------•--------------------....----•-•••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LITL is 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beo issu -by the oard ie 3
Sign ? ................� - °2
Date
Application Approved BY .. -- ------------------------------- ----,7------/,:-.^:
Date
Application Disapproved for the following reasons---------------------•--•---..........------------------•------•----------------....---•••--••---------•.......--
Date
PermitNo.......aD ._3 .------••-•-•--•--..... Issued_.......................................................
Date
No. .... �? Ftzs...- -0.....:`.....
THE COMMONWEALTH OF MASSACHUSETTS
_
BOARD OF HEALTH
Appliration fur Uiiipuu�al urku Towitratrtiott Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair / an Individual Sewage Disposal
System at:
.................................................................................................. ..................................................................................................
Location.-,sA�ddress or Lot No.
�fJC h'S
.........
Owner / Address
Installer Address
Q 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 ......................................................
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.
Seepage Pit No--------------------- Diameter--------------...... Depth below inlet.................... 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_____-__.-.-_--•-__-___.
GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___--__________--_.____
04 -------------•-•--.....---•-•••••------•------------------..........•---•--------•-•--••........•............................................................
0 Description of Soil........................................................................................................................................................................
x
U -•-------•--•-•--•-----------------•--------•-•--•--•------•------------•--------•------•--•------------••-•-•---------•-----------------••-----------•--------•-----•-.._.....---------•..............
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---- ------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------
U • -- / c:o S i t i� L/�/e-)-
U Nature 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 iiT`. y g g p y
of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has be issued by the oard ef`h th ' . J
Sign .. ----- �/ d
Date
Application Approved BY .............................. -----
Date
Application Disapproved for the following reasons---------------------------------------------------------------•--------------------------------------------•----
....-----•------•----•-------------•-••-•....._.....---------•---•-------•----•-•------------•--.....--•-I-•--------•--•--•-------------------•--•-----•-------------•-----••--•----------•--••--••--•---
Date
Permit No........ =--=--
r-� ' ........................ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ GU...... ........OF.../�" a.v �` ...................
%T�rrtifirFatr of fwoutpliFanrr
THIS IS TO ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ,`"rr�....... ...f:�.......
------------------- -------------------------------------------------------------------------------------------------------------
........ Installer
----•---•.......................................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...._..F8........� 5 ..... d-ated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............... c..-... .-.�5. ................................. Inspector.................
................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,--,OF HEALTH
--------------------------------------------------------
No.... ` ...
FEE. '
Biapofi al Workii C�onu#rur#ion rrutit
Permission is hereby grante -- - - ••-• - ---•- --- ---- --------•--------------------------------•-••-------......-•---•-----•-•-
to Construct ( ) or Repair ( an Individual Sewage Disposal System
at No.-----•--••--•-•-•- � /l/f� �/v C� �9 / 6-
-----------------•-----------._...----=---------------------------------------------------------------------------...........
Street ,
as shown on the application for Disposal Works Construction Permit No.._!�CJ/.),�_ Dated..........................................
Y`�'�
Board of Health
DATE----------..✓.. C -•-•-----•-•-----------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS