HomeMy WebLinkAbout0154 BARNSTABLE ROAD - Health 1��ern stt�.b� � �D
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD / . HEAL
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����� «» �� � Works�����ww � ���� ���� Tn�&otrurtio4� ����u�tut
Application '
� b��vmad for Permit � ) Repair an Individual Sewage Disposal
ner dress
Dwelling of Bedroo ---..--IIxpauoino tic ( ) <3uz6uge Grinder ( )
Other—Type of B o. m6yersoog�'-.'�����-^.- Showers ( ) -- Cafeteria
04 Other fixtures
~� ' ' -_---.-----_--.-------_---_--.-------..----.---------'----.
Design ...........Lgallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank[
Z Other Diacrivouvo box \ / Dosing tank \ /
~~ �
Percolation Test Results Performed 6y.......................................................................... Date......................................_ �
�
Test Pb No. l................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 wuter------.-'
0 --_-' --_.-_ --.--_-_-'-.........................................................
Description
of Soil. '--_.----'-_----_.---'-_'''-
-------`--`-`----`---''---`---'---'-'-`—'------'----`-`--`--'-`--'--------`-------
_-_.-------._-._-._---_-'..__.-_--_.--_-------.--.--.--.-_--.------.----...'--___-
U Nature of Repairs or Alterations--Answer when applicable,---.--------.-----_-----_-----._-.�
.......................................................................................................................................................................................................
The undersigned agrees to install the uforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een i ued by t board o�fhealth.
Date A
pplication Approved l�y'-. ~- _ �_�
at
� Disapproved for the following rxaxoms:------.-.--.--.--. ...........
-.....-----'-_'_-'-_-'----_--_-._--_---'-----'---.-.._-'''--...---__''--_---'------_------
|
| Date
'Permit ' o"e _-
^``---`--`---------------- --`-`'-`-`--`- `------- ----- ---
No..._ Fica...........:` .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEAL. H
'..... ....... a F......... 4 . r'P ,..P
App, iratillit fur lghqvviial Works Tuuotrurtilau Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System t
44 ...........................
6 ^ i� .......... --------------------------------------------
F i.., d` ; ,yet.
Orrn'er £',�'' Lot o.
...... b �.... or ddress ..........................^............
.. ....................................................
Ins a Address � fe
UType of Building Size Lot....�:..�..._.� '�..�:�q. et
Dwelling—No. of Bedroom ....................„ . .. .............Expansion Attic ( ) Garbage Grinder ( )
0.4 Other—Type of Building, „f o. of persons. .._/.40.. ... Showers ( ) — Cafeteria ( )
Q' 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_ An.sq. ft.
Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by._---------
--------- .............................................. gate---------------------------------------
Test Pit No. I.........:......minutes per inch Depth of Test Pit.................... Depth to round water........................
(z Test Pit No. 2................mmutes.per inch Depth of Test Pit.................... Depth to ground water........................
•. ...
..--
0 Description of Soil•---- .. f!
U •---------•---------•••-----••------•--•--•---- ............................................... -•-•--------............-------••---............ ............•••••......--•---•---•-------------------.
w
U Nature of Repairs or Alterations—Answer when applicable.----------------------------•_.-----_--_-:----------------••--:_---_--------•----------------.
---------------------------------------------------------=-----...._...----------------...----------------------------------------.....--------...--------------------------------------------....-_----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article xI of.the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ued by th board of health.
Slgne . ................
}> Date
Application Approved By........... �t, . -- /� D<
la Application Disapproved for the f of ozvinq reasons:-----------------------------------=------- -----------------------------------------------•----------....---•-
.............................................................-................................................................... ......................................................................
- Date
Permit No........................................................... Issu .a'
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
.... . OF....... ' '
rl - "�" ".'..................................
C�.er#i,ir��P
T S IS 0 RTIFY, That`the id,ividual e -, e Disposal System constructed ( ) or Repaired ( )
li ------------------------------------------------------------------------------
<. >talle� r
at.. .. ..
has been mstalled in accordance with the provisions o _ rticle XI of The State Sanitary Code a —describe in the
application for Disposal Works Construction Permit.No o......................................... dated-
THE
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A (WARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----- �'
Inspector----
nspector- :, .r' a ..,... . ' � ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALT
.. ....F ..... OF......... : : s...............
FEE.No.... `.... ....
r ,
Permission ' hereby granted T .:- .� ?>�f, ...`................................... ..............
,:
to Constru ( ) x Rep r } a Individu Sewage Disposal System
:... . . 1� :f `�
�<,... J
at,No:..�. ... R ........ ........ .... .........................................................................
Street
as`shown on the application for Disposal Works Construction Pt No.. atea ,�.E _.
x�
a ' Board of Icalth
DATE_....
---- •-------------- •.....• ......
FORM '1255 140 BS & WARREN. INC.,-PUBLISHERS