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HomeMy WebLinkAbout0525 GRAND ISLAND DRIVE - Health I 525 GRAND ISLAND'7�'\VCOSTERVILLE A= 70-8-10 I r e o 15 TOWN OF BARNSTABLE LOCATION SEWAGE # 9 i41-52 7 VILLAGE J`���ti, ASSESSOR'S MAP &LOTS eO 8 0l4$ INSTALLER'S NAME&PHONE NO. -2 %�u.9 4t, l5r SEPTIC TANK CAPACITY LEACHING FACILITY: (type)-%LZWi l (size) -56 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: C'!� — ��` � �COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by -4 10=53' Y" 4- it sr, � 0 l Y -.15 7 Fiz$....... ,c .a.... THE COMMONWEALTH OF MASSACHUSETTS f -7 EN BOAR® OF HEALTH p ............. W .............OF.. a' '���................................ ApplirFation for. R-4poii al Workii Tomitrurtw"n ramit Application is hereby made for a Permit to Construct ( eo�or Repair ( ) an Individual Sewage Disposal' System at: 2. .. � . - rL... i'1 •-•---•-•..• -----.-. Loc ion-Acdress �— .-..-. .•--or Lot No. y/ win/er///J(� .............................................Address � � Installer 01 Address d Type of Building ,��j Size Lot....1+ ,.14q.Sq. feet a If Dwelling—No. of Bedrooms................................ Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ............................ No. of persons.....--..........--..--.---. Showers ( ) — Cafeteria ( ) d Other fix ,ures . W Design Flow................*....S....................gallons per person per day. Total daily flow......................... --gallons. WSeptic Tank—Liquid capacity 511M---gallons Length-_------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No. ....... ......... Width................ Total Length----- SO..._ Total leaching area--------CAZO 7.-sq. ft.. Seepage Pit No.-_------------ --- iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosin tank ( ) Percolation Test Results Performed by-- .... ' Y.f.... r............... Date........ ...... aTest Pit No. 1......)........minutes per inch Depth of Test Pit....- G>o�... Depth to ground water-----.:----........ (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----••----------------------•----•-•-• ---•---.....• ..... O Description of Soil 1�5.. A .. /dL°)/ ------------------------------------------------•---------------- Ux ----••-••-----------•-••-••-•-----------•-- � �- ,t��... -------------------------�---- --... -�='----••-���3-- p------- --14-�-per-------------------------------------------...-------....---------------- W --••-•-•------------------ . --------------------....-----....---------------------------------------•---------•-----------------------------------------------•-- VNature 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 Environment Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance a been iss t e board of health. �y Signed ... ------ ---- sip :.e .............. Application Approved By ..---....... ... ` -- ----40� .-. Dve Application Disapproved for the following reasons: ................................ ........................... ...... ............ .... .......... ............................ ................................... ------ ...... . ........................................ ........---....... --------................ ---- ---------........---- ---------- /� Dare Permit No. .....1.3 --7------------- Issued ------.---- -------- ------------------------ Dare No----------------------- FizE.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ApplirFation for Uiipuaaal Workri Tnnitrurtinn Trani# Application is hereby made for a Permit to Construct ( 4 or Repair ( } an Individual Sewage Disposal System at: ................_.......................................-----•-•------•-------................. .......--------•--------------------------------------............................................ Location-Addresst^ or Lot No. •-----•-------------- P'.rr t� , t�t.a l. 3 �7_T" Cv'I�; ... .................................................................................................. - - Owner Address W Installer Address Type of Building Size Lot_._. '___,. .- ___._ q. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -------•------------- --- . Design Flow................`,S....... ...........gallons per person per day. Total daily flow............................2.ml: ..._gallons. 1:4 Septic Tank—Liquid capacitya`'.'.= ..gallons Length---------------- Width---------------- Diameter................ Depth................ Disposal Trench—No. .......�I_...._.... Width......?_.......... Total Length...._1 f ..... Total leaching area----- !.{'?'---sq. ft. Seepage Pit No-----_------------- Diameter.................... Depth below inlet.................... Total leaching area_...............sq. ft. Z Other Distribution box ( `) Dosing tank ( ) t '-' Percolation Test Results Performed by 1'">1 r t . .............................................1" il Date............................ ...._ Test Pit No. L.._`.-...____minutes per inch Depth of Test Pit_----f!2_.5�.... Depth to ground water---- "�'"'----___ . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----------------•-•••-•--------------••-•-•-•-----• ....................................................................................................... AA ="D Description of Soil.................... ........---•- .....-•-- ......S -------------------------------------------------------------- V -------------------------------------------- -- 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 Compliance has been issued by the board of health. Signed ------------------------------------------------------------------------------------------------------------ ---------- -------------------------- Date Application Approved By ------ ------- ----------------------------------------------------- -- --------- --- ----------------------------.................. --------------- ................ --- --------Irate e------------------ Application Disapproved for the following reasons- ------------------------------------------------------- ------....---------------- -- ---- ------.........------------------ ------------------------------------------------------------------- ---------------------------------...................------- --------------------------------------- Date PermitNo- -------------------------------------------------------------------- Issued ---------- ..-------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS -.-� BOARD OF HEALTH /.t :4/l OF . ,, -A - "C -tA.--------------------------- GEr#tfirate of C11IImytianre THIS IS TO CERTIFY, That the Indi 'dual Sewage Disposal System constructed ( tom"' ) or Repaired ( ) by ------------------- � - --------------------- --------------------- ...... - ��- Installer at ��`....-.. � � ---- - ��.---...... �'..: - Q = .. has been installed in accordance with the provisions of TITLE, 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No./'l 4�.......... dated --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. /�'I 'j DATE.. ��� ��1�.' .-- — Inspecto �2� 'P`1� -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ? ���1.......OF.......x .::t •............................. No......................... FEE........................ nrk�" �.�n�#rilan .eranit Permission is hereby granted..............................................-------------------•-------------------------------•--.......---------.................••...--- to Construct (1-') or Repair ( ) an Individual Sewage Disposal System atNo......................................................................................................................................................................... ..................... Street as shown on the application for Disposal Works Constructi"on Permit No..................... Dated.......................................... •-•----•---------•---------•-•---•----------•--•------------------------•--------•--------••---•---.----- Board of Health DATE......................... -•----•-•----••--....--•...............•---.....------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r s ^a I �.��.+-•.. 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