HomeMy WebLinkAbout0285 CHURCH STREET - Health 285 Church Street
A= 153 - 020
W. Barnstable
Vol
LOCATION SEWAGE PERMIT NO.
VILLAGE
I N S T A LtER'S NAME , i ADDRESS Lam✓
S U 1 L DER OR OWN ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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THE OoMA AR®®ALTHFOFUA�S'SACH i SETTS
Jr� .....oF........
.:�. ... . ............
Aliptiration for Disposal Works Totaotrurtioaa Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: ��/��
...... --......._......-• ... -` ----•-•.....................•-...._---•-•-- --•.....------•-•------------......_------
omti -Address or Lot No.
— ..... .. .• ................ ........ ..........-------•--•-----....•--......_.....---••-...............................................
Address
al . - . ........................................................ --------------- ---------
Installer Address
T e of Building Size Lot............................Sq. feet
U Dwelling Building
of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
~ Other—T e of Building No. of persons............................ Showers —
a
Pk YP g -------------•------------•- P ( ) --•--.Cafeteria ( )
dOther 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. 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........................
-------•-•--------•-•-•----------•---•-•---•------------••--••-•--------------------------•----•--•--.-----
ODescription of Soil........ ' -------------•-------------------------•---------------------•--•-------------------•----._......--------
x
U Nature of Repairs or Alterations—Answer when applicable__/�Z� ------ ................... ______________________
----------------------------------------------------------------------------------------------••-•-•---------------------------------------------------------------------..................---.
Agreement:
�.
The.undeisigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'I'll 5 of t e State Sanitary Code—The undersi ned further agrees not to place the system in
4 0 operation until a Certificat of Compliance has bee issued by e bo o e lth.
Signed. ..: --- --------- ------ ----• .•----- . ....... . ..................... d(
Application Approved By... = '_ }_ I Dt
�� _. - - ----------------------•-••---•---•--•-----•---........-- �`------.I-- �-•--•--------
# \ 1 Date
Application Disapproved f or the f ollowin�g Yr�asons----------------•----••-----•-----------•-----....................--............................................
-•................•--------...---•--....----•-----•-•------------•------•-•-----•-•----•--...-----........---•-------------••----•---------------...---------------------...-----•--------------•-----••-
Date
Permit�No.."t': ---•------------------------------•-------- IssuecL..................................................
/ f Date
- - --- - Y---- --- - ------ - �. - �.��.�----------------- --
' dw yam'
No...... ""� - �9 !'
Fx$.1........f:..........._
THE COMMONWEALTH OF MASSACHUSETTS
-- BOARD PF HEAL_
.� .. ..'. OF...r'.
Appliration for 14spusFal Works Tonstrnrtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--•Locat n-Address or Lot No.
� e_
f .� �r f �Qvwner Address
_ ....:.:... : .............:......... ..�..: ,... .......------•--.....-----••-••-------......naa ...........---•..........---.............-----•
Installer Address
U T e of Buildin
g Size Lot------------------=--------Sq. feet
Dwell
Grinder
P4 Otherl—Typeoof BB ldi gms......................... No. of perrsonsnsion Attic--(-----)Showers (GajbageCafeteria ( )
a' Other fixtures --------------------------------
W Design Flow............................................gallons per person per day. Total daily:flow--------------------------------------------gallons.
WSeptic 'lank—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
a 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........................
Description of Soil........- 1 '` _ 'x l
U -----------------•---------...------------...._...--•------ ---------------•-------•---••-•--•--••--•-----------------------•-•---------•--•---•-------•---
W ------------------------------------------------------------------------------------•----------------------------------------------
----------- - - �-
UNature of Repairs or Alterations—Answer when applicable._ I.-71°'______________ .................. ..I.........................
...........................................................-............................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT12 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boaA 9j.health.
Signed_ r�� �t?° .......... '...._J ?� /'`£ '
Application Approved By—S..-- ...... .........r
Da
Application Disapproved for the following reasons-------........................................................................................................
...----••-•---------•----•••-----••-•-----------••-•--•---------------------------------•-------...---•••--••-•--••---•••--•--•-----••------------------•--•-•----------••----•----------•••------......
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
Tardif iratr of Toutplianrr
TM.-W I, TOf,CERTIFY, bat the Ind%vidual Sewage Disposal ,System constructed ( ) or Repaired
by.....� i° _ "'? ' �`......---:� �` `•---- '� ----.. ......-•--•----
,� r ,� .�
o rr s y' t✓per * Installer ..
at r , F✓ r/ d >, ,'. 'r ` /: 1 ./� /`lc(
. ......
------- -------- -- ---------------- ............................................................�a ' +
has been installed in accordance with the provisions of TIT4-L-L 5 Oi{ J-Otate Sanitary Code as described in the
application for Disposal Works Construction Permit No.........................................�It
dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE.. .......................�•--L-� -�......�..----...--•--------- Inspector........----- =
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF7 HEALTH f
l- ILO O F.. �''r`�.,f`',. e ;i�, , ✓,�'` /� '" ... fr .f'.../•.....:...
J . �v
P 0......................... FEE. ..........
Disposal 10nrko T5nn t ion famit
+3,+'.r/'/t'"�f F,•J�rr=fir�i°�-,=`Y ^�� I_.✓.f,�'��� �r•,",rs�+
Permission is hereby granted: .-----. ........................•---- ------------------------... ...................
to Construct.(� or Reepaar�(� ) an Individual;_$pwage DispgsW, Sys�t n r
�T�
= l :. --
Streett �iL9
as shown on t4.gplication for Disposal Works Construction Permit 1ol. .............. Dated..__._._ _'_t'. ......................
...... -----
Board of Health
DATE..............................................--............ --•-----
FORM 1255 A. M. SULKIN, INC., BOSTON r
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