HomeMy WebLinkAbout0025 MASA'S PLACE - Health (2) a5 mOA s
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 8srnt�table APPROVED
TOWN OF BARNSTABLE cor o ment
Appliration for Diripwial �ii orkii Tomit r#io 7 9_?-
Dat
Application is hereby made for a Permit to Construct ( ) or Repair ( V5_"an Individual Sewage Disposal
System at:
con-:\ddre_
Lo ati s or Lot No.
................. ---------------------•- •-----•-
Owner � Address
�-. Y lo-------------------------------------
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of Persons.- ._____--___------.--__ Showers Cafeteria
( )a
dOther fixtures --------------------------•--------•---------•----------------------------------------- --------••----------------------------•----------------------
W
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
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----/P......... Depth below inlet----C. ......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........................................
aTest Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 -----------------------------------------•-•----•--•----•-•-----•--......-•--••-•-••--•._._..................-•--.............._--•--•-•-••-•----•--•-•---•--
ODescription of Soil...................................................-••-•---.........---------•-----•--•-----••---------...--•---•-••-•-•----...-_.._....---................._.....--_..
x
w
UNature of Repairs or Alterations—Answer when applicable.---: ...... ��} ...........
P-/...........................................................................
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 as been i sued bqthe board a health.
-C.
Signed .............:. ...... . ..... .... -- - ----------------- .-:..... ......... ".7%`
Dare
Application Approved By ...............
�....� ............................. ............................ ......
Application Disapproved for the following reasons: ...... ... . .................... ......... ...... .......................................................
............................... ............. .........................................................................-- ................................. -.......................................
CDare
Permit No. ............/.....�J. -...h�---------------... Issued
Dare
k
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diripooul Works Tomitrnrtion� Prutit y' - s�
Application is hereby made for a Permit to Construct ( ) or Relxtir ( Vy"an Individual Sewage Disposal
System at:
..............'--'-.�............1r � 5 ..... ......
-'------•----••--------'-----'-------------------------------•-------------..._..........-----'--
Lorrtion-`:_�ddress j or Lot No.
.................. (�.✓.. ': .�1..`...— 'a'�7i-` - •�-'" --_----------••_•-•-•- •------_---•---t--`-�f�._/�/L�( .c...................................................
r Ow r
W `
1 -'Address
----------•------------- ---------------- .....
,a Iitler
/!»if
Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms---------------------------------------_.--Expansion Attic ( ) Garbage Grinder ( )
aOther Other—Type of Building _.......................... No. of persons.-.-_--__--_________---.---- Showers ( ) — Cafeteria 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.
3 Seepage Pit No.....I.............. Diameter----`......... Depth below inlet....(. ......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by.......................................................................... Date........................................
a
c ..l 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........................
? �+ -------•.......................•-------------........._........._.......
0 Description of Soil-----------------------------------------------------•----......-------•-----•-...----•••----•-•--------•-------••--------------------------•-------........._.......
x
V
W
xT•••'-� --T------------
U Nature of Repairs or Alterations—Answer when applicable.-_--TEk��T. _j(___..l G?ll ................i c ................
() f!': oSc� S�'j�J am' S�✓+� — Q-- oy ........ ...................... .......•--•--•----... ...........
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:•iaa has been i sued by the board o health.
Signed ------ -- <—.'..... ...._ .........:........ L�:..7`. ._? ...
Date
Application Approved By ............... ......fir
Dare
Application Disapproved for the following reasons: .........._............................................................................ ............................................ {
............. .................. ....... .. . . .......
................................Dace...... .-..............................
q� Dace
Permit No. .......?....��_-,��?, --------------- Issued
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertifirate of Tomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ..................... ..4a.....G.._c_. w ..5- . �f (-.................................................._..__.................................._............I................... ............
� InsnJicr
at ....................................... -'� - ��------A.....I � � ��� VJ:..0 .�. ----------.�.-J!.F7.ti � ..............................................................
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. .....F3-_.1�,�............ dated ..............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. --`
,............... �` --._.......... ........ Inspector ................. ..~�
DATE......................_ .'�� a2.... -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No._.9 .-..J FEE,;;. -_'�...
-....
14sposal Workii Tonotrurtion Vrrntit
Permission is hereby granted... _ .4:��_._L-�-W...zf�---� ( (-
to Construct ( ) or Repair (C_-aw Individu ^Sewage Disposal System
atNo...............•-----•------.....-----------•_.... ............./// l�
'Street qq
as shown on the application for Disposal Works Construction Permit No._/.T�_"Z3. Dated...........................................
...............
7-D.......................................................
gBoard of Health
DATE............... < ------------------•----------------
-.
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS