HomeMy WebLinkAbout0055 SHELL LANE - Health 5S t�.r'e-
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TOWN OF BARNSTABLE i
LOCATION cS� S` `-� ;EWAGE # a
VILLAG (XJ (J-- �'�ASSESSO a
--{R7�('S MAP 6(� LO
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INSTALLER'S NAME fa PHONE NO. e!""J 1c0-k
SEPTIC TANK CAPACITY 600
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE.WELL OR UBLIC WATER
BUILDER OR OWNER � � ; -,
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED: �--�D /
VARIANCE GRANTED: Yes No Ll _
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No._ .��.._.... :�d Flcs.... Q---.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.-..O.OnlP.4..........oF.... Rr-RY -tb- ........................
Allpfiration for 11isposai Worts Tonstrur#ton 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair (L-)-an Individual Sewage Disposal
System at:
-
........ ..54 : .:...�.-: ......_........... .................• OT U j-------------------------------•----.............---..
Location-Address or Lot No.
.........
w et A 7 es �f
l�f r //Z/-
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...- _______________________________:._-:Expansion Attic ( ) Garbage Grinder ( )
aa Other—T e
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ....................-=-----------------------:...----�----...------------•--------•----...---•-------•-- ........................� ..................gallons per person per day. Total daily flow__�.� _____.__.._-___..._.___._gallons.
WSeptic Tank'--Liquid capacity/gallons Length...F..... Width_-.,.y........ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length............... Total leaching area....................sq. ft.
3 Seepage Pit No...../............ Diameter....../4-..... Depth below inlet....6............ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. l________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 Test Pit No. 2................minutes per inch Depth of.Test Pit.................__- Depth,to ground water........................
P4 .........................
•---------------
••••--------------
•.............
•.........
....
0 Description of Soil.................................................................................................................-----------------....___------._......__...
U .-------------------------------------------=-•--•----...-----•-........-------:._..------......---•-••----------••------------•-•----------•-------•-------------•-•-----....---•••--...----••----------
W
x5 -- --------------------------•-----------_-____-------
U Nature ofair or Alteration =A saver when appli bled___________________T .____ls' -..-
--
...=.Fs,/ _
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ham ued by e&RLQLie lth.
Signed---------------- . ----- ------------------
Date
Application Approved BYe""
a c� =:_ <_
Date
Application Disapproved for the following reasons---------------•----....-------------------------•------------------------------------:_..-..-•----........._....
............................................
............................
............................................................................................------------•-------••--•-----•-•_•--
/�� �zc Date
PermitNo....................-....---------------------..__..... Issued_:_....--------------------------...:---------..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OI�G�C..........OF...
........ ....... .....
. 142/I.....T�4�j
....... .........................:....
Trrtifiratr of Toutplinure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
bY.......................... ...... ��--------------.......---------------------------------._......._............_..------ --
` Installer
at.......................►7--•-1 '-----_. S �! 4•--x u t
----- ...........................................:--------••--_...._
has been installed in accordance with the provisions of TITL: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.----- ,t �_20_-____.-. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION, SATISFACTORY.
DATE................------------------ ---_...__•-•----••---•------------------- Inspector....................................................................................
ice}....
No.. ...... ... Fss..
THE .COMMONWEALTH OF MASSACHUSETTS �-
• BOARD OF HEALTH _
r pphration for Disposal Works Tonstrurtion Prrutit f
-Application is hereby made for a Permit to Construct ( ) or Repair ((�)an Individual Sewage Disposal
System at:
��1 1� 1_
•--•------.....___.._..._..... .:.--- .... ! ......_........... ................Cn ' ........................_.............
-•Location-Address or Lot No.
..... __._.... .......... ........
.a ..............
Owner Add
lac P!. ..�.:.1A!!!! l r '�C=-------------•-•-•--•--....
..........
. -•- ....................y Installer Address
Type of Building _ = Size Lot............................Sq. feet
Dwelling—No. of Bedrooms__� ............. Attic ( ) Garbage Grinder ( )
a'4 Other—T e of Building .............. No. of ersons.............._.._.......... Showers
YP g -••-•-•-•----- P ( ) — Cafeteria ( )
d Other fixtures . .._..- ...
W Design Flow......\�-<-....................gallons per person per day. Total daily flow.7Z ........................gallons.
WSeptic Tank•-/L Liquid capacity 0�llons Length-__ '....... Width...-/...... Diameter................ Depth................
x Disposal Trench—No. .................... Width............._...... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.................. Diameter......46'.)...... Depth below inlet....6............ Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by...••-•----••--••••.._........•---•--------------
•-------•---•------------ Date........................................
04 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
- fz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•-•-•--•------•..........................•---•..........--••--......_..........._..--•-•---•----••--•---...--•-•.._...._....•-•----•-•••-•--•---••••........
0 Description of Soil........................................................................................................................................................................
W
h U Nature of Re airs or Alterations—Answer li�le._... � �lb -
AA
._ �.:. ...: ..: ..... _�Z 'h .. :.. .. :.- : -- ----------------•••_.....Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in Accordance with
the provisions of TITLL 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 tkhe-board-of hhi Ithh
F ^ .
Signed. ... -• ...... -- r
t 1' Date
Application Approved By.................
r
Date
Application Disapproved for the following reasons: ........ --•-----------................... ...........................•.._..._......-•
4
n
^ Date
PermitNo.-------- :..c 7 ................... Issued-.......................................................
Date
-------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH` _
...................................
Trrtifiratr of Toutpliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b _�= `°•''�� �- '�' �' 7 C ............................................................................................
` t Installer
at........................) �.......--S � •-.....
has been installed in accordance with the provisions of TI'i'L. 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... ........ dated_-_........................................•...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... •-----••----. Inspector....................................................................................
— ————--—————————————————————————————— -- . ——————— ---------------
THE COMMONWEALTH OF MASSACHUSETTS
�r
BOARD OF HEALTH
�6 �L/ ��....,.. .................................-,......-..........._.... FEE
Disposal Vorho Tonstrurtion Vernfit
Permission is hereby granted......_G': 1" ._ -• ? ....... r
- ----------------------------------------------------------•---
to Construct ( or Repair ( )•an Individual Sewage Disposal System
at No - _
Street
as shown on the application for Disposal Works Construction Permit Dated..........................................
••--------------'•---•--- -•- ' — -------------------
Board of Health
DATE------- ---------- ........ ` :...