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HomeMy WebLinkAbout0030 NICKERSON ROAD - HEALTH No.... P Fss...: ( .. ........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................... ....................OF............................................-----------.----..........................._.. Appliratiun for Uhipoii al Workii Tuntrurtion ramit Application,is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --- ------------------------------------------- .................................................... n b W es ........•._........ Lot No. Address . . -- ..... --•.. ........•----•---._.................... . ......•---••---••.............._..-- -•-•....---•-_..._. ........................ Address ©� © d Type of Building Size Lot. .:.......... Sq. feet U Dwellingk$�o. of Bedrooms....:!.....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria P4 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. 3 Seepage Pit No....../------------- Diameter... Depth below inlet.................... 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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ tom-• - - ------------------- 0 Description of Soil---- ✓ .......---•----------------------------------------•--- -- --.-----•------.---•----•-•--••--•-•-••..... x W ----------••---------------------------------- . V Nature f Repairs or Alt ratio s—Answ when Ea livable. ___ __ ::.. ..................... ....... ......................................... � - . .....---••--•------------------------•-----------------•------...------------............---•---•---.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE , 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliancei neds;;4,been ssue th�ar health: P g � Date Application Approved By................ 0\.K� _ Date Application Disapproved for the following reasons-------------------------------•-----------------------------------------------------------...:-----------•---. .....................••........---••--•....._._......---........--••-_•-•----•-•--.._..................--------•-•-.._...-•--•-••-•----------•••....-•--•--•---••••-•••---••---•---•-•--•---•-........_ q Date PermitNo.......... -------------------------- Issued............................... ---•------- Date 'J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ..............................O F......................................---------........._................................. ApOiration for Disposal Works Tonstrnrtion Frrutit i Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at , a .... -.o.... ?c .. ..% ... ....................................................................._..............._.......... ,lLoccaatiop%-Address or Lot No. ...rY."..�:�r.-:_•+'^~� /S/1..';�^:.Se: ;l?:r� �:.�u�.................. . .......------....------......................................................................... caner .Address �' Installer Address � � �U O Type of Building ,, Size Lot. ..........................Sq. feet U Dwelling�No. of Bedrooms.... Garbage Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures ---------------------•-----•-.---.----------.--•-- - Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No,•-_-----•-•------- Width........._.. Total Length.................... Total leaching area...................sq. ft. r . Depth below inlet.................... Total leaching area..................sq. ft. 3 Seepage Pit No.._.../.....:........ Diameter._...�. ,�_ • 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........................ 1-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . ......---••......... . ..........•------------•--••----•-•..............•-......................................................... O Description of Soil.... . �'��-�f � t . U ..................... •--------------------................-------- -.---------- •-•----- .............•• --....---.-------•-•------•----•----....------ W •-••-••--••••--------------••----•----•--•-•--•-•-•-----•----••-•-...---••-•-•------•••-•-•--•••--•------.•-••---- - ............................. UNature f_Repairs or Alt ratio —Answ when a icable.--�`�' ���� .. p, :...� :.....................•---•-�.......--------------.---.---•-....--------::::............-----.------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITIS 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the boar health. Signed. t .. — ................................ ............................... Date Application Approved By................ � •--w,..- ... ......... ..,-...T-- - t_ Date Application Disapproved for the following reasons:.........................................................................................................--- .........................................................................••---•-•-----.......................---.........-•-----•------•--.......................................• -D�•--•-••---•-- c�y-•..............._.._ Issued.........••-••.......................................... Permit No.----.....�..`�S._..�.--I- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. . �t..........OF............Y -t 4-ij&A1_C................................... Trrtifiratr of (rontphaurr THIS IS TQ CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired � '`�: . by.............••• ........ .. ......... I tall •-..._.............--• ....................._...--•-- ....._...._ -- I tatter p at---------------- ��.....-v. —=�!' I'3.a^---..... C q-•��....---------............----------------:.............-•-------........................ has been installed'in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... .�f._:___ .,<.......... dated..............r........._._..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............................•----....-------------•-••-•-•--.................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q+ ......... C9CTti2..........OF......... ................................. Disposal Works Tons#rnrtion f rrntit Permission is hereby granted........... fps........................ to Construct ( ) or Repair ( an Individual S wage�Disposal System atNo............ . ... �_ �,yr1- ....� ......_ .fz. . : :r:is........----•--•-••-------.......-•----........-•-----•-•----.................. Street i as shown on the application for Disposal Works Construction Permit No(�. .:..c1 _ Dated.......................................... ............................... -r ................................................ � Board of Health DATE................. ............................ FORM 1255 A. M. SULKIN, INC.. BOSTON l_ AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATIONZt tac-fL ces�T� 4-, . SESVAGE #: ,r?/f VILLAGE ff ' L.E c c ASSESSOR'S MAP &.LOT% k ' S INSTALLER'S NAME & PHONE NOS- � A SEPTIC TANK CAPACITY LEACHING FACILITY:(type) {size} NO. OF BEDROOMS 3 OR PUBLIC WATER BUILDER OR OWNER c -�- DATE PERMIT ISSUED: " DATE . COMPLIANCE ISSUED: le " VARIANCE GRANTED: MW ti r http://issgl2/intr.anet/propdata/prebuilt.aspx?mappar=018059&seq=1 4/19/2013