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HomeMy WebLinkAbout1800 OLD STAGE ROAD - Health ,. ;� .. , __ _ r- I I TOWN OF BARNSTABLE LOCATION ���C7 C��[) U � �� SEWAGE# VILLAGE W, C3G,l t-,5 \OAQ, ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Scek\ 'C:f,.N,,V,- SC)k 2cl U 00 SEPTIC TANK CAPACITY k- L LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER W�:S� cSnS .��- CA 6 PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of any wells exist on r 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 C� �� o prae0SZ No. •-•` d�� F�s.. .........". ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH /00 " 1 OF. . IS2- 00 ,A��VIirztfvn for Da vii al Works Tonitrn.r#ion amit Application is hereby made for a Permit o Construct ( ) or Repair ( ) an Individual Sewage Disposal �p stem at .... ............................... -------•-- ................................... ................. . U3 �. I .. Coca' Address or Lot No. ,.,. - ..........................----- ---••....__......._...........................------ ` a O r Address :Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Build No. of persons___________ _______________ Showers — Cafeteria Otherfixtures .-----_--------_---------------------------------.-----------------------'---------------•------------•---------------------------•.........------ W Design Flow..........:....................:............gallons per person per day. Total dailyJow.._...................._....................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 ( ) r 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......................... x --------------------------------------------------------------------------------------------•---------...------------------------................--•-••.::... 0 Description of Soil.......................................................................................................................................................................... V M ------------•......................................................................................... ..... ...... ..• •------• - U Nat e of Repairs or Alterat onri—Answer when a licabl ._ _ _ �...�_'�-�-�o0............ .:........................... �1•-R.. - ` 1....._.. •---.-o�.te:-'......-----•--•--------------------------------------------•--•--••---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'IU 5 of the State Sanitary Code—The undersigned further.agrees not to place the system in a operation until a Certificate of Compliance has b issue by the board of Inn = � � • a y ` Date Application Approved By-----�---- ---- .•-- 7 ........ .....7.7.... Date Application,,;Disapproved for the following reasons:.............. ............................... i ................................................................................................................................................................_. .... - n :Date Permit No...........:.... Issued I- -•------------ Date x No.. �.- ----- p Fps .... ....'...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Xpp try ttlan for Ut*VniiFa1,. ,arks Tnnitratrttnn ramit Application is"hereby made for a Permit to Construct ( ) or Repair ( ) an Individual •Sewage Disposal System • ........................ . ................. ...... .../3.. .................................... ............. - .Address ti.Tir/ ......l�o n y •-•------•-•---..---....or Lot No. An -•.--•-•---•-•.Address ' W Yx .... •••.................... -----•-----•..............................• M Installer Address QType of Building �• .� „ '�-"'"� Size Lot............................Sq: feet V Dwelling No. of Bedrooms............................................1 x anion Attic Garbage Grinder p, Other—Type of Building _____________________ Na x of persons............................ Showers Cafeteria ( ) Q' Other fixtures .. !_. _ .......................................................... *F W Design Flow' .......................... • gaif6ns per person per day. Total daily flow y ........................:_,_ •..gallons. WSeptic Tank-Liquid capacity r g ,` g p. allons � Len th............... Width.__._..__...... Diameter...._ . De tl1................ x Disposal Trench—No.............t �.._.. Width ,Total Length.................... Total leaching area`"_� ...sq. ft. -1 Seepage Pit No..................... Diameter _-__ *...... Depth,below inlet.................... Total leaching area... ......sq. ft. Z Other Distribution box ( ) �`Dosing tank (ram �{ a Percolation Test Results Performed by. d ............. Date... "_ . ,.a Test Pit-No. 1................minutes per inch Depth of Test Pit.....1......_..._... Depth to ground water------------------------ Test Pit.No .2................minutes per inch l?epth off Test Pit...__........_...... Depth to ground water �. ---------------•-••----- .......................................................... Description of Soil --------------' ....4...... . . ---- :.. .-- ..%...------------......-------•-----•-------------------- W :....-•---•-•-••- •-----. H i:�y:,2, V Nathre of repairs o lter ions—Ari wer when a plicab � ....... �. © . ----•-------------.................. ............................................................ Agreement: *: The undersigned agrees to install tlr aforedescribed Individual Sewage Disposal System in accordance with „# theprovisions of TITTLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate 4 Compliance h si I issugo by the board o h th. rS ned, '( .......................... `... ............... .. ~ taE6a -� Date Application Approved By:__.,�f .. .- - ; - .. .S_'__ '...'...._.. 5 Date Application Disapproved for the folk owing reasons:.................... •° ... ...................................'..........._........_................_...._........_..........._.......--._._......._. s °Date R,ermit No....................................... _ _,.-" 4 F ;;. Issued-............. ' vk S d Date % .x s.okU THE COMMONWEALTH OF MASSACHUSETTS ,:.„•► BOARD OF LTH . . .. ry . .............. ......OP Trrttfirzttr'"of Tnanpli anrle r r I I 001SERTIFY, That hen widual Sewage Disposal System constructed ( ) or Repaired ( ) by .. ..••_; . ............................ ---- •----•------•--- ------------ --------- •---- --- ,b at ......has been installed in accordance with the provisions of TIT IL 5 of The State Sanitary Code as de�cribed in the application for Disposal Works Construction Permit Nd.. .__✓_f ..............._.. da.tect'.. ............................... THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE` SYSTEM WILL FUNCTION SATISFACTgRY. DATE.-•---------------------------------•---•---........ -------------•••-•..._.. Inspector.............. . ................... THE GNIMONWEALTH OF MASSACHUSETTS ` »,. BOA OF HEALTH 74 ............................Y. ... ..................................................... y N0........ .. FEE ................... 1 rtrr nat # Permission is hereby rant d...._ . . .. r to Cons ( or pa>r ( a Individual Sat v ispo System c . ••••• .....•-•._...---••--•••-•. ..........••-- 5 Street - l7 Yr:. as sown on the application for Disposal Works Construction P t No Dated ., ,r ••� ......... ............................. }S 77 Board of HealtH DATE.... l ... --••------...... •--------------•-------------------- FORM 1255 14OB8S & WARREN, INC.. PUBLISHERS