HomeMy WebLinkAbout0026 DAMIAN WAY - Health (2) t
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THE COMMONWEALTH OF MASSACHUSETTS
BARD F i-�EAt_TH
...- OF........ ------
Appliration -for Bifi uiittl orko-,Zowitrurti vrr, ulit
Application is hereby made for a Permit to Construct (d' ) or' Repair an Individual Sewage. Dis osaI
System at
._.. •. ---•-._•.•. ... -•-- •------ _ �. --••-------
e � or
= +- . ? .:..' ��' �//�1�3°��:`+�%�4-dui" �=—a _ ..
' /O®®wne .�^� .�-�_� //�� Address
. ..... - --- -----------=--- !!�` 'l
Insta er Address
Q T e of Buildi Size Lot............................Sq. feet
U
U Dwelling No. of Bedrooms.... Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P Other fixtures ..... ...........................................
--------------------
W Design Flow__ ________________`�----_--�.____.__ gallons per,person-per day. Total daily flow_-_--__ _..gallons.
WSeptic Tank —Liquid capacit, gallons Length................ Width...__.....__". Diameter__-.....-_.----_ Depth................
Disposal Trench—N :-Widtl ___________ _____ L rg tal leaching area----.--._---. ---_-sq. ft.
Seepage Pit No = Diameter-_,l_dDe th e Total leaching area sq. ft.
Other Distribution box ( ) Dosing tan s
aPercolation'Test Results Performed by— -:. --.;------------------------------------------------------------ Date..........----------------------...
Test Pit No. I................minutes per-inch', Depth of Test Pit-------------------- Depth to ground water....-_____-._.-__._._..
Li, Test Pit No. 2........__.,_._.minutes per inch epth of.Test Pit____________________ Depth to ground water.....__--__._._-
o .r,.. - --- eZ ----------------------------------ZDescription of Soil-----=----- --
U ---------------------------------------------------------------- =-----------------
W = -•-•••---
a9 x --
.U. Naturef Repairs or Alterations—Answer when applicable._.--_..� ..� ....... ..........................
s 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 issued by the oar of It "
I.. - ---- --------
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APPlication Approved BY / S /4:�;arte
- .... .
ate
I
Application Disapproved for the following reasons:........................... .......•__---.---__-_--_--___--__-_-_-_--.--------.-_-_--__.-.-----_
-------------------------------------------------=-------------------------------•-•••-•-•-•--------- ......... -- ........�;..................... ---------------7b "Daie--------------
PermitNo........................................................ a Issued.---
Date
No.. __3s..... Fss... ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.�.vfrafian -for Uti uiittl Works Tutu4rurtion rrutt#
Application.,is hereby made for a Permit to Construct (/' ) or Repair an Individual Sewage Dis osal
system at
... ..... __ -- ...... •.._ .... - -----_ ._ _ _.. .. .
= .
-___-
s
Owne Address
A!�,.f......
Insta er Address
d T e of.Buildi Size Lot___________________________Sq. feet
U Dwellin No. of Bedrooms______:_.______�"'� E�f ansion.Attic Garbage Grinder
g aer E P ( ) g ( )
Other—Type of Building -_______________•__________ No. of person>,.,___------------------___. Showers ( ) — Cafeteria ( )
Other fixtures --------------- -
,qq -:---- ----- ------------------
W Design Flow__________________ L.�______ -gallons per person per day. Total daily flow------- gallons.
P4Septic Tank rLiquid capacity gallons Length................ Width____.._.------- Diameter----------------- Depth.__-_____-__---
xDisposal Trench—N .................... Widtl Qtin t�l leaching area--------------------sq. f t.
Seepage Pit No.__:____� Dtameter__� ____ D e ____ ___________ Total leaching area
Other ft.
z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed bY-------------------------•------------------------------------------------ Date........................................
Test Pit No. 1................minutes per inch Depth of "Pest Pit____________________Depth to ground water..... __-____-_._.
(s, Test Pit No. 2................minutes per inch pth of Test Pit____________________ Depth to ground water__.___________.:_____._.
O -
Description of Soil '�----- �
` --
x ...........
d
W
--------- - ----- :; ---------------- ------------------- =
U Nature of Repairs or Alterations Answer when applicable.`- '__.a- _ 4 --------------------_...................................
.
•-------- .:
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 syse'm in
operation until a Certificate of Compliance has been issued by the oar of It
Sig -- --•-'• -- -.
ate4
-y!
Application Approved BY _-- -::•--_••-- ff ,�
Date
'Application Disapproved for the following reasons:...---------_---------=--=----...... == --------------------------------------------------------------•--
.--_-------•= -•--•------ -------- --------------=----------------------------------------
Date
PermitN6......................................................... Issued..................................-••-------•-------•---• .
• Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
oF........, .............. t� G� '` .-............................,
Trrttfiratr of :TVuntVltanrr
HIS T, vl t the In i ua ewage Disposal System constructed ( )` or Repaired ( )
staller
at. •----
171��--------_-- r - --
has been installed in accordance with the ovisions o Article XI of The State Sanitary Code/as d �crrib in the
application for Disposal.,Works Construction Permit No.-________ _ _.__.__.___. dated -__ , '.._/ _ _:_. :-_--.
THE ISSUANCE OFHIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE HAT'THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................................................`_:........................... Inspector.............------------------------------------------------------••-••-=
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
..., ......OF......... . ....+.."•.. ...........
FEE... ..........
-
Permission is h )bDy gran d ..._.....;toConstru ( ) re a• ) an Indty du Sewage Di 1 Stii stem
at No. --.. :
.
Street - -,
as shown on the application for Disposal Works struction t No". _ .._ 'Dated__._ .J� ______________
o d of ealth
DATE .'. ---------------------------- t
y
FORM 1255 HOBBS & WARREN. INC.. PUBLISHER$
TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMSVALV��- r-AG:k3
ASSESSORS NAP NO. go? PARCEL NO. dJam— U p•
ADDRESS: A, c.C® 4 y VILLAGES X34/c 4iS E
CONTACT PERSON PHONE NUMBER 34 v,�-
LOCATION OF TANKS:. . CAPACITY:- ..TYPE. OF' FUEL AGE: TYPE: LEAK
OR CHEMICAL: DETECTION
/0 U� �U-4- Pico ---f�= SYSTEM
DATE OF PURCHASE OF EACH: 1. Z 27� 2. 3. 4. 5.. _
DATE OF FIRE _DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
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