HomeMy WebLinkAbout0035 BLUE HERON DRIVE - Health 4Q �1�e, leror� Lk
TOWN OF BARNSTABLE boo-o
LOCATION Lc 5 v-e L SEWAGE #
VILLAGE (/SI-F -1'c,t /t o ASSESSOR'S MAP & LOT `17.o
INSTALLER'S NAME & PHONE NO. C7-yo .oLl 6-4-yAL4
SEPTIC TANK CAPACITY o"
LEACHING FACILITY:(type) �� C��is5f cy (size) / ( ��_ -
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER I/(",
M'
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED
VARIANCE GRANTED: Yes No: ; ,
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR OE HEALTH
.........:.*"-O.\s.,.t)...--------oF...... A. ��.��.-. .LE..............................
Appliration for Bhipvii al Works (famitrnrtann ramit
Application is hereby made for a Permit to Construct ( ) or Repair. X an Individual Sewage Disposal
System at
................ _.---.--... -.... ...._..... .._..........- -
•Lo at' n- ddress
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Owner Address
W
Installer Addresses
.—
d Type of Building Size Lot............................Sq.
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Q)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------------------• . z
W Design Flow........ �.........................gallons per person er day. Total daily flow--------.sJ��9......................gallons.
WSeptic Tank—Liquid capacity_Tallons Length--- 5.. Width_4-710. Diameter"___-"' Depth.S_•55_.
x Disposal Trench—No..................... Width.....YZ.......... Total Length...3-I.J........ Total leaching area..AS�Z...sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box Dosinnk ,, ll _
Percolation Test Results Per _.Per-formed by._... AX A,-J4��a-_.I-4L........ Date..'3`Z'A` 9�
Test Pit No. I____Z, ...minutes per inch Depth of Test Pit...>0.......... Depth to ground water...AA.....-...........
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-•------------------------ ............................... .....--
O Description of Soil.......Q--2 1-1 ---Yvl Fj � ) ...----)- ...act........-.. -.
x
W ----•-----------------------•-----••--------------------------•------------•-----------•----••-----•-----•-•------------.....----------•-•------------------•--------•-------------......--•--•-••--•---
UNature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
� ........ health.
system in operation until a Certificate of Complia has b en issued by e oar o
Signed ............. :� ..........
..
y --- ......Application Approved B � :.�' t� ✓ .....................................
Date
Application Disapproved for the following reasons- ----------------------------------------- --------------------------------------------------------------------------------------------
- ---- -- ------------ --------------- - ---------------------- - -------------------------------------------- ---- ------------------------------------------------ ........................................
Date
Permit No. .--._ '..... Issued --..---._ �.....�....� �
Date
C_.
No..........;:'... ...�.{�'? Fima...- '. ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,OE HEALTH
.....................�a,{-.0._.......OF.....1../7 ' .fit ?. .: �i ,.��
----- ..... ,-----------------------------
Appliratiun for Diupuml Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct (,ram) or Repair X an Individual Sewage Disposal
System at: �'t t� '`t 4�D&.A o�,� +�=: 05 t i .�:�-' ..... ................
..... .--- •
Locati•n- ddress
Owner Address
W n
Installer Address 2
UType of Building Size Lot......:5�:............Sq:'feef
1-, Dwelling—No. of Bedrooms............................................Expansion Attic -�Q Garbage Grinder A0
pa, Other—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ................................. .
1
W Design Flow......... . '`..........................gallons per person per day. Total daily flow.._......)J............................_gallons.
WSeptic Tank—Liquid capacity.V.Mgallons Length__-:: .. Width.:.-! Diameter_'-7-- '. Depth�`5':.1�)..
x Disposal Trench—No..................... Width.....k.......... Total Length..3?.A......... Total leaching area___.-: `5:...sq. ft.
Seepage Pit No-----------_-------- Diameter.................... Depth below inlet.................... Total leaching area..........:.......sq. ft.
z Other Distribution box ( 4) Dosing,-tank )+ `
Percolation Test Results Performed by.....� ?�." t-_:!._t`'j�=:...�.�C........ Date._ '�' :..r'�.................
a
Test Pit No. I.... _`—_..minutes per inch Depth of Test Pit...1Q.......... Depth to ground water... ift...........
G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-_________-___----__-_-
a ------------------ -- ..... ------........................ .
O Description of Soil �` ."P'< ...................... .....�. ...........:. .......--...-.-..'.,...---............. ...........
x
W ••-•-------•-------•------------------•••---•-•••••----------------•----•--------------...•-------------•------•-•----------•--------•-••---•-------•------------•-----------------------•----------•---
UNature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliano has b en issued
by._t e board of health.
Signed ...... y- { .......................................................
.r 11/ ..A..�-----------
Application Approved B
s
Dare
Application Disapproved for the following reasons: ------------------------------------- ........-----............................................------------.._-..----------
_ ----------------------- --- --- -------
�• 1 ,� l�,.,. � Date ...,..->
x
� Wit...-- Issued ........_` o. �^E: :.. ":- -'Permit No. `t--. ..........-
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH _
.............................................. .........
Ter#tfira e of Tomplianre
THIS�0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------------f k `` t.... .��':"�'f-----.�'--'%. '"9. r°,.". ---...-.-..-....-...............
Installer
at . - ;��.. --.-------..--� _...........�......�-�.-� ..........:.. �f f ----.------ T .4 l.,t.(w,, ............................................................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Cgde as described in
the application for Disposal Works Construction Per No. "' ''�"$ �` `'`% , �� C
:' dated . = r`.
e-THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. .--- — q --...............---. Inspector ........---- s
C-- - ------ -- --.3 - ..-- ---- -- ----------------.... --..-.....------
THE COMMONWEALTH OF MASSACHUSETTS
_._..., BOARD OF HEALTH
OF
No.. : �..'.... r FEE.....:............
%vvsal� urkv Tun,�tr tiun rrmi#
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Permission is hereby granted =...... ...�'''...�` '�.....--- ........'?t;......:_..................................................................
to Construct ),—o Repair ( �an Indivi,d. Sevt agg,Dis esal System
at No......... .51=k2 {"V c�»f U... ,! ,(1 l LI c�. t '-�+ 1 .L
........... ..................................... ----------------•-•---•-•-••-• .....--•-
Street
as shown on the application for Disposal Works Construction Permits No-�__';,,__.`/ _,�Dated.._..._�._....r:".'.-..:...._....'d
................•....i° . _.a
f Board of Health
DATE.. ..........................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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No. 29733 "' No, 19394 ,
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