HomeMy WebLinkAbout0120 THIRD AVENUE (HYANNIS) - Health (2) NU 4i(-d Pmuej
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NA. 10334
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MADE IN USA
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No.----.. ...... Fmic.... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q r _.-
OF XA�000. ...-�tSl ................AW*;.�5_..--
Appliration -for UioVooal orko Tonotrurtion Vrrntit
Application is hereby'made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
T
Location Address r or t N
_ - GL------- ---- r s
.. Ow e1 ..Address
Installer Address
Type of Building Size Lot............................Sq. feet
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.
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. it.
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.__._____-_..__._-._....
t=, Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water----.---.-_-_--._____._.
-------------------------------------------------........................................................................................................
0 Description of Soil...........................................................•....--------------------------------------------------------------------------------------------------------
x
W
-- ----------------------------------------------------------
UNoure of Repairs or Alterations—Answer when applicable..._._ : _' k!oz--__.---rc-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal S stem in accordance with
the provisions of Article XI of the State Sanitary Code— T>e7vnqeTsigned further agr s not)to place the syste in
operation until a Certificate of Compliance has bee ssu y bo
Signed C� .._
---------------- ---- -------- --
�/ Date
Application Approved By..----- ---➢------------------------------------- ----- ----•........:/__:Pa2_'-_�_7.
Date
Application Disapproved for i.e following reasons-----------------------------------------------------------------------------------------------------------------
------------------•-----•--------------------- -------------------------------------------------------------------------------------------------------------------•-------------------------------------
Date
PermitNo.------. a... ----................................. Issued........................................................
Date
No.....f .?....... FEE.... .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. pplirativai -fur Uhip ial Norkii C owitratrtinat Vamit
Application is hereby'made for a Permit to Construct ( ) or Repair ( . an Individual Sewage Disposal
System at
..�
Loc do Address or t
Owe Address{
Installer Address
Q Type of Building s ,; Size Lot----------------------------- feet
U Dwelling—No. of Bedroom ___ . ___Expansion Attic ( ) Garbage Grinder ( )a Other—Type of Building _-_______-- No. of persons ................. Showers ( )____:_�_.__.___._ p S ( ) — Cafeteria
Q, Other fixtures ----------------------------------------
d -------------- ---------------------------------------------------------------------
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 ( )
Percolation Test Results Performed by---------------- --•---------------•-----------------------------------•-- Date----------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.-._-_--_--________. -.
(4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__.__.______.__._____.-.
9 -------------------- ----•-•-----------------------------------------•---...---•------•-•-••--••-•-•.........................................................
0 Description of Soil__________________ .
x
V
W
Uure of Repairs or Alterations—Answer when applicable.. 1 }
r J'
V.0-0-1K. - [�s�_f' .# /�c _,h _
-------------------
Agreement: ' '
The tindersigned agrees to install the aforedescribed Individual Sewage Disposal S tem in accordance with
the provisions of Article XI of the State Sanitary Code—T, un rsigned further agr es not to place the system in
operation until a Certificate of Compliance has beenyiss ;t board.�f i.
r
Signed.-._..
Date .,
ApplicationApproved By...... - r-----____-- --------------------------------------------------------------- -- Drate
Application Disapproved f the following reasons:._.. ---------------------------------•---...
_____________________________________________________________________•_._____________-_--____________--_-._________________________-______________________---.-__.________________----__;-__________-._-- +.
Date ,
PermitNo..... --�--•---•------•--••--------•------------- Issued........................................................
Date
i ' •
THE`COMMONWEALTH OF MASSACHUSETTS r
BOARD OF EALTH
t
(WITIrrtifirate of 1095.1lutphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by.............. - _ n
ro Installer
at.-.-. Y �eSani_tary
----•--••---•---
has been insta le Inn accordanceY lth' the provisions of �rtic'e' XI of The S Code s described in the
application for Disposal Works Construction Permit No._.___._....f��:_`7................... dated..._________�''� -
THE ISSUANCE OF THIS CERTIFICATE SHALL, NOT BE CONSTRUED AS A GUARANTEE THAT THE �N
SYSTEM. WILL FUNCTION SATISFACTORY:
DATE................................................................................ Inspector---------......::•------•-•--•-----................................................
mob„ • � ••
THE COMMONWEALTH OF"MASSACHUSETTS / � lf't ifd►/ ,g
BOARD OF HEALTH (�
OF.... ..�� •
No....... FEE ...........
isp0r,a1 k Qlaatfitratrtion ramit
Permission is hereby granted --• ...-•--••--......-��-- ----------------------------- .........
to Con ruct ( ,,�l or Rep i ) an In vidual Sewa Disposa yste '� s Y t
at No. !. •-- .. `
...
Street
as shown on the application for Disposal Works Construction Permit No _- -- -- -:r------- Dated- ? 7
^ -• h
�e Board of He th
,
DATE....._1..... �---7_'7-------------------------------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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