HomeMy WebLinkAbout0028 FOURTH AVENUE (HYANNIS) - Health ��.,
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TOWN OF BARNSTABLE
LOCATION SEWAGE 1#1 - `d
VILLAGE hig�iUAX, ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITYwyas
LEACHING FACILITY:(type) Sr4 1;211 TRA"Tn2S 7 (size) `t
NO. OF BEDROOMS '3 PRIVATE WELL O PU�WAT
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: a
VARIANCE GRANTED: Yes No
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No.-- ---�....... � Fps..........................
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TH COMMONWEALTH ,OF MASSACHUSETTS ,.
BOARD OF HEALTH APIP
TOWN OF BARNSTABL ,�►!ED
Appliration for Disposal Works Tate tr r _ #�'
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sew is�sal
System at:
............. .........•-.( out�............................. .............
fP�L&tiocaSti�on_.-_Address
..... .. C1A - o..r..L o.t...N..o
.......... ---- .............
Owner Addr s .6 !�
-
S.e. ..N(....................... P�UA - •• ... ko . S!. ?... •---
Installer Address
UType of Building Size Lot.................... .....Sq. feet
Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ( ...................
------
W Design Flow.......... ................ allons per person per day` Total wily flow
Diame�ter...�___.._. Depth-.-gallons.
WSeptic Tank I Liquid ca acity_ti�allons Length----V.....
x Disposal Trench—No. ��. f l.. Width-...�f............. Total Length..=...�f)..._.. Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dying tank ( >-------•------------------•-----...-------••------- Date........................................
a Percolation Test Results Performed b _________________ ._..
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........................
a --••-•----•--••••••----------••----•--•---------------•-••----------•-----------....--------.................................................................
0 Description of Soil........................................................................................................................................................................
x
U --------------------------•---•-------•-••---------.....---•---------------••------•-•-•••----------------•-•--•------------•-•---------•-•-•-•-••---•-------•---------...----------.....---------------
w
UNature of Repairs or Alterations—Answer w1�en applicable__.. i�s:ST.F��_�:...i_>.(4_0 ..
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 Compliance has been ' sued by the board of ealth.
Application Approved By ..... ..........................
Dace
Application Disapproved for the following reasons: .....................................................................................:..................................................
.......................... ....... ............ --.....................---........................----------.................---------------------.......----- .................D--a--te-------------......
PermitNo. ......... ... ..... ....................... Issued ----------------------------........................................
Date
R-
No.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Disposal Works Tonutxttrtiun irvit
Application is hereby made for a Permit to Construct ( ) or Repair ((/�an Individual-Sewage Disposal g
System at: Q `^ /
..............�1^__.......
..... .y_S�_ C.hIL���Lot N�
.Location-Addresso.
r
- Owner Addre s
W
P Installer Address
UType of Building Size Lot...........................Sq. feet
.-, Dwelling—No. of Bedrooms.....�__.?•...................................Expansion Attic ( ) Garbage Grinder ( )
aa Other—T e of Buildin
YP g ----•-•--------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ........
W Design Flow.......... .�..................... Ions per person per day. Total daily flow....
-�_.____.....................gallons.
WSeptic Tank 1-Liquid'capacity_VSr-'_ ns Length Q._... Width... 2 _____.. Diameter------------_-- Depth ----------
x Disposal Trench—No._ Kl Width_._..k_____________ 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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........................
a •---•-•--••...........••----••••-••-•---•--•-----••-•----•---••-••••-••......---•---.....---•-------.........................................
•---------------
0 Description of Soil........................................................................................................................................................................
(.� -•------------------------------------•---------------•--------•---------------------------.-_------••----------------------------------•-------___--------•-------------------•---•--------------------
W
UNature of Repairs or Alterations—Answer when applicable____ [v .A_�_.`--.__1_ __Ux�_
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 Compliance has been issued by the board of health.
Signed` . /: �.. t
r/ g
Application Approved By . - ---- ------ ----
Date
Application Disapproved for the following reasons- ------------------•------------------------------•---•------•----------------.....---------------•-••-•-------........................
.................................................. -- ---- ----....--------------------------.............----------------------------------------------- ----------------------------------------
� Issued� pare
Permit No.
Date.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Olelc#tfirat.e of Cgomplin re
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
by : �... .. 1=....� .> k�--'�- ._. :� .-� -4.......................................................................
�, Installer
at ..............................c�...-...L'.... (^ ............................r ..7. ►. .�. S °'�
.... --------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5W he S Envi'fbnmental Code as described in
the application for Disposal Works Construction Permit No. ....... ... ., ._ dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUARANTEE THAT TH
SYSTEM WILL FUNCTION SAT SFA ORY.
DATE--------------------------- Q Inspector . ;
t q/ -
THE COMMONWEALTH OF MASSACHUSETTS
/ BOARD OF HEALTH
'�' TOWN OF BARNSTABLE JV
No._ - _..__�- FEE...... _
Disposal Works Tunutrurtiun "prrutit
Permission is hereby granted................
............................................. _
to Construct ( ) or R�ePair ( Individual Sewage Dis osal System
at No............. /T l" u-� -�!�l �Z�.� G ✓rT 1------------------ w. -•----
---- 4*-F
Street
as shown on the application for Disposal Works Construction Per No.-. ` __ ted_.__ ..............
------------•--- -------•-----------------•---•-••-•---•--
/ F/!
BoaFd of ealth
DATE...... __7
FORM 36508 HOBBS✓!c WARREN,INC.,PUBLISHERS
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