HomeMy WebLinkAbout0070 GOSNOLD STREET - Health �D (oasnola .�-�-�-
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HE A T'H
Appliration for Disposal Works Tonstrurtilln Prrmit
Applicatio is hereby made for a Permit to Construct ( ) or Repair ( ' an Individual Sewage Disposal
System at: •-•.•-�
'..... d� .: .. .. . ..... ._.... ............... ....................
—.•_•Location•Address
.
Owner Address
40
W 4_
. : . . .. ........._.�...... .. .....a
Installer Address
Type of Buildi Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( )
PL4Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures .................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid capacity............gallons Length................ Width-__-_-____-__- Diameter................ Depth................
xDisposal 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 ( )
PercolationTest Results Performed bY.......................................................................... Date........................................
Test Pit No. I................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........................
LY, .................................
ODescription of Soil.................................. -•-•--------------------------------------------------------------- -------------------
�4
U -••-•-.._..----•-------•-------------------------------•---•---•---•--.......-----•----------•---••-----•------•----•---•-----------------------------------••--•••-----•----•-•-----------•---------...
W --------------•--•-------•---------------•-•-------•••-•-••-•-•••-•-----••--•••--•••-•--------------••......---•-------- ------------= ' --•--
UNature 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 furthkarees not to place the system inoperation until a Certificate of Compliance has n issued y th oard health
Dete
Application Approved By............. - -1 {•icy
Date
Application Disapproved for the following reasons:.....................
...................................•--•-.........------••-••-------------•--•....------------•-----.......-•-.......•-----------------------------------•----......••-------------••-•--••---------•-----
Date
Permit No. ...... Issued.... S` —
�. _ . .. Data
_...... .......--.
...�_....� -._----
No.../�L�A�.... Fimim.. .........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEf-% TH
Applicatiop is hereby made for a Permit to Construct or Repair (.01�) an Individual Sewage Disposal
System at:
hf
Installer Address
Other—Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( )
PLI Other fixtures ...................................................
Design ..gallons per person per day. Total daily
Septic Tank—Liquid ............ Length---------------- Width................ Diameter_--.-.. Depth------.-.
Disposal Trench--No..................... Width-------------------- Total Length.................... Total nrou---------ag. ft.
�t Seepage Pit 0o.-----'--- Diaozctcr_.---_--' Depth hc1ovr inlet---------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'- Percolation Test Results Performed bv.......................................................................... Date........................................
Test Pit No. l................minutes per inch Depth of Test Pit.--------- Dcuth to ground water........................
44 Test Pit No. 2-------'.minutes per inch Depth of Test Pit-_------- Depth to ground water........................
.- .............................. -__--'---'----''--'--------------.----------- �
0 Description o6 Soil---_--__-_----
----
U Nature of Repairs or Alterations—Answer when applicable..f!!�:.....le- V-1 IS
The undersigned agrees to install the ufore6esoibed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code The undersigned furt6eyr not to place the system in
operation until a Certificate of Compliance has b8en issued y thehoard health.
Date
-------------------------.-----_-----'--------------_--------- ---
Permit No.- ________ ��-�i
al
THE oowMowvvsAcr* OF MAsSAo*uscTrs
BOARD OF HEALTH
T�j I S I S TV) C E uIntifiratr of"T-j'autpliana
VR Tl?l e Disposal System constructed or Repaired
I�Y That the Individual Sew/
has been installed in accordance with the provisions of Article' XI of The/State Sanitary Code as,descDlbed in the
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL O �������ly. �
- �
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r*s comMomxvsxLr* or mmssAoxuesrrs
BOARD OF HEALTH �
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os shown uu the application for Disposal Works Construction '
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ronm /une n0000aw^nnsw. INC.. ruauoxsns �
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�t T Town of Barnstable
Inspectional Services
.A MABS.MASS 1� ' Public Health Division
.¢
1ssy.
Mora Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Fax: 508-790-6304 Office: 508-862-4644
AFFADAVIT FOR A BED AND BREAKFAST
PERMIT EXEMPTION FORM
f) 3;14 --019
Name of Bed and Breakfast: �� ��
Address: 7 Z) a
Telephone:
Name of Owner: c�G�
Telephone Number:
As Per 2013 Food Code, State Sanitary Code MA Regulations for Minimum Standards
for Food Establishment, Chapter X - 105 CMR 590.001 (C)(1) and can be found on
website: https://www.mass.gov/regulations/105-CMR-59000-state-sanitary-eode-
chapter-x-minimum-sanitation-standards-for-food
I attest I am qualified for a Bed and Breakfast Permit Exemption because I meet the
followinn criteria:
fI Owner Occupied
N, Available guest bedrooms does not exceed 6 .
ti�'Number of guests does not exceed 18
I�] reakfast is the only meal offered
The owner/operator is responsible for ensuring all consumers of this establishment
are informed by statements contained in the published advertisements, mailed
brochures, and placards posted at the registration area that the food is prepared in
a kitchen that is NOT REGULATED/NOR INSPECTED by the FC-regulatory
authority.
G
Signature of Applicant:
Date:
C:\Users\bellaird\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\92XFOMQD\Bed and Breakfast
Exempt 2019(2).eoc