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Home My WebLink About0765 OST.-W.BARN. RD - Health KMS c� S M E A No.2-153LY UPC 12934 smeadmom • Made In USA Z5, v %WW 0 SUSTAINABLE FORESTRY INITIATIVE CwHad Fiber Sourcing rrograu�org TO N OF BARNSTABLE LOCAT;aN �9 wEWAGE # d VILLAGE SESSOR' �3d AP Sz LOT � p INSTALLER'S NAME & PHONE No SEPTIC TANK CAPACITY LEACHING FACILITYAtype) (size) _ NO: OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER L,4— r DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED- VARIANCE GRANTED: Yes No � L I 9 ® O1 No.R.. a 3 - U Q Fi&$..... d............ -- Srr c� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALT ....................................... o F.............. '� Ap;i traflou for Uiillnsal Worko Tomitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair (� an Individual Sewage Disposal System �at: ®1' ..............1�.`'.�._........�?....`1�Sc..v'a-'......_��___�_._.....--------- -----------.....................----------...---------------------•-------------------............ �\ Loca i Address or No, n wner Address r le Installer Address dType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms...__................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit__-_-____---___-__- Depth to ground water........................ a' ----- ---- ODescription of Soil---------__�S- -------------------------------------------------------------- ------- --•------------•------------•---- Ux 3 ••----•.....----•---------•----•--------------------------••------------•-•------•---•---••---••---••----•----------•--•-- ---------------•----------------------- W -- --- --------- -------- -- ----- U Natur of Repairs or Alterations_ Answer when applicable._.._``^�--. --________________------------------------------------------ °`®?_ ... c Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL 1Z 5 of the State Sam y Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s en iss ed by the b rd of he 1th. 00 �e r� Signe • - -----..=..---------• _----_ `-?---A ----o----•-- Date Application Approved By---•------•...... .. -Q 9 Date Application Disapproved for the following reasons:..................................:.:..... -.............................................................. ..............................•-------•-....------•-•-------------•-------•-••---••----------•---..........--------------.....----••-•-------------------------------------•----•--------------•••-•-•--•- Da.. Permit No.......... -..1��j--•.................... Issued.......... _-".a- .. t. ...... Date No................_....... Fss......s,L_�,........ THE COMMONWEALTH OF MASSACHUSETTS `--]BOARD OF HEALTH A 7.... � ........ ...... .....oF.......:-........................................-:.. ------ = Applira#iun for Disposal Works Tonstruriion rumit Application is hereby made for a Permit to Construct ( ) or Repair (P-) an Individual Sewage Disposal System at: n Locatid Address or Lot,No. •- - .:v ......................................' .....-- wner 1 Address ' ..............••--..............`......•••---••-------•------••----•--•-•-----••-•-•--•--•--•. Installer Address Type of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms...... ..._.•..........................Ex Expansion Attic a — p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other 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 ( ) aPercolation Test Results Performed by.................................................................-----•-• Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ or, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•------•-•-•---••-----------•------•--•--•-•-•...-•--------•--------------••--•--•----••-•--............................................................... DDescription of Soil----•---..'S_ .. —----------------------•----------------------------------------------------------•-•---------------------••------------------ V --••-----•---•---•-•-•------•---•------•-•-- ----------------................................................. ............................................................................................................. V Nature of Repairs or Alterati ns Answer when applicable......V__ -- = fi = ----- ................................................ , Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT112 5 of the State San�afy Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has `pne'.enAw issued by the board of health. r1 Signed:. W`--� .. ..�.. .. U r Application Approved B -. _ e^ PP PP y......•-----•• -••---Z- --------------- Application Disapproved for the fo owing ons:. �_____________________________ ..Date............. . •--------------•----••-••-•••----......_....-•--•----••-•--••--•---••-•--•......--....•-----........•-------------••--•-•-•-••------------•---•---•------•----•----------••--••-•••---•------••-•- Date �(y' `�: / --. Issued------•-•-- Permit No..... Date.-- ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ?.. ..................................OF....... . ........'� !s .................................................... (9rdifiratr of Toutpliattrr TH�Si) IS TO,CI?RTIFY, That the Individual SewaR Disposal System constructed ( ) or Repaired by.........,....�°i � � . v z. ......................----••-----•...-•-......--••....----•----•------------------•...........--------••••--•-.........-•--•-. Installer r at........................ --------.-- •-•-••----•---k•-•-------------------------------------•--•---•---•---•--------------------------- 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.__... ....... .... dated............ ................................... THE ISSUANCE OF THIS CERTIFICATE SHALL 'F B�CONSTRUE® AS A GUARANTEE THAT THE SYSTEM Wd LL FUNCTION SATISFACTORY. �d DATE................................. ....................... Inspector.......................W'..)2� THE COMMONWEALTH OF MASSACHUSETTS BOARD�OF HEALTH ........:.C7 .OF....... %.......................................................S No......................... FEE........................ Dispo al Works Tontr�ion rrmi# Permissionis hereby granted. --------------•------•--.•------•-- --•---------._...-----...-•---------------•--........•----....................._.. to Construct ( ) or Repair (� Indivi al Sewage Dispos 1Systemr atNo..............•-••----•-• - J.. .... .. r...r ---•-• -----••..-•--- Street b as shown on the application for Disposal Works Construction Permit ------------ Dated.... ........... .................. ....................... -----------------------------------------••------ oard of Health DATE...........` - . 0y.................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS