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Home My WebLink About0291 RIVER ROAD - Health veri 4 TOWN OF BARNSTABLE LOCATION 921 Q��' R1 Z) SEWAGE# VILLAGB M I (IYA I LA 2 —ASSESSOR'S MAP&LOT4 0 Q 41� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER YA) L F10 PERMTTDATE: 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 �' --- i+ I � -- � �� `� S� - `:. 1 �� , _ � 1 �� j �� -= �� No.. - - Fas..-........ 49..... THE COMMONWEALTH OF M SSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphration for Diripuiul Mor1w Tomstrudinn Vantit Application is hereby made for a Permit to Construct ( ) or Repair (4.-<an Individual Sewage Disposal Systems at Locai:@mi-Address or Lot No. y.. ._....._1 . . -,. ..�.� . O«ner A dress 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 ( ) 04 Other fixtures ---------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter................ Depth................ 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........................................ 04 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------------------------------------------------.......................•....... .........•........... .•-•---------------------------------- ODescription of Soil........................................................................................................................................................................ x U ------------------------------------------••---......-----------------------•---------------------- --••--------------------------------•------------------------•--------••---•••---•-••-----•--....... W x ------ ----------------------------------------- --------------------- --- U --Nature of Repairs or Alterations�Answer when applicable.-.--.-_� ----------- .. —................ .................... ax •• �� 7Z1k� 'L ,.. -------------------------------------------•----------------........-----..............---. 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 Comp4aae has bq� d by the board of health. g �' Si ned ...... f Date ApplicationApproved By ----- .. .. ................................... .....a....... . .............. ... ..... ... _.-----------.....--- ..............--ate---.......------ Application Disapproved for the following rea on • ...................................................................................... ........................................... ..... .................. .......................................----------.................................................. Date Permit No. ... .. ...........3..- .............. Issued ................�.��1 ... .. ..........e...... ce I r: t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i f i TOWN OF BARNSTABLE Appliratiou for Ui►ipwial lVnrkii Toutitrur#inn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (4-f'�an Individual Sewage Disposal System at: LOCat-1tan.-:' dd ress mot_or Lot No. ............................ ................ Owner Address ............. Installer Address UType of Building Size Lot............................Sq. feet t-� Dwelling—No. of Bedrooms------- --------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow................................................_...._............gallons. j 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........................................ a Test Pit No. I................mmutes per Inch Depth of Test Pit.................... Depth to ground water........................ fit Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... O ----•----------------------------•----....--------------•-------....-------------•--...............•......................................................... Descriptionof Soil.............................•-•----------------------...--•--•--•-•-------------------..---•-----------•-----------............--•----•-•-•-••-•-•----•-•••--.......... V W ••-•....................•-.--------- ......-----------......---•-•---------•-------- U _-Nature of Repairs or Alterations Answer when_applicable_..I .......... C�_ _ ............ r� .....o - !- �x -------•-------------•-------•----.-..-.-::.. 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 Com ' c'ce has bep-.i•ssu d by the board of health. A .Signed ...... . .-9 < - ... .. Dace -m-------��Application Approved BY .......... Da e.................. Application Disapproved for the following yearonik ....................................................................................................................... .......... ....e ...................PermitNo. .....�. - Issued ................ -.--.�.�.... to THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 'ITV Ertifirate of "Tomplianre I THIS IS TO -- RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ..... - Q�------------ ---- .. ....... n.------------... ........................................... } .; �Incr.Jlc•r at ............. . ::.. .. ..... ....�........... .......0--. --...�::......... . ......... . ........................... ........................................................ r has been installed in accordance with the provisions of TITLE of The Stat vlronmental Code as described in P the applicationifor Disposal Works Construction Permit No. ... _. dated ........ .. ... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / _ ........ Inspect rr--:- T�t�-.. .........._..........._......... ......... DATE_.......(..�.......�._......� - -.... _.... � �- I' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F TOWN OF BARNSTABLE �D No....l ........... FEE........................ �t��n - � nrk n�trttrtinn �rrutit Permission is hereby granted._..... ._�°'�`_� �;J��.t------- :--•---------------------•---------••-•---.....--•--... to Construct ( )or Repair ( vran Individual Sewa e Dispo al\System Street � �f as shown on the appli tion or Disposal Works Construction Permit No. .1.. Jy/_ ,:ted.../1�--,1---........................ /n \,� " Board of/Health DATE-------------------- /r ' l//% U 7t-7 FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS