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HomeMy WebLinkAboutApp-Permit-Compliance.....................2 Rux THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF Appliration for Disposal Works Tomatrurtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal -ystem �-u t o ..................... _ ►� ... `DR c!2rr ( r - - Jl ------------------------- ' :. (? .-•---......-...._.._._...... ? . `� Los31�Qn n- Address or Lot No. - -- .c.................................................................................................................. �a ner Address .--� --c-�-- �`+I----;--"."' 4'r:........................................................................ ......................................^--- Installer Address d Type of Building Size Lot ----------------------------Sq. feet U Dwelling —No. of Bedrooms ...... . ...._Expansion Attic ( ) Garbage Grinder ( ) 04 Other — T e of Building No. of persons--------•------------------- Showers Cafeteria 04 Other fixtures ------------------------------------- W Z W W w P4 x U W U Design Flow............................................gallons per person per day. Total daily flow ............................................ jEtllons. Septic Tank — Liquid capacityk©M__gallons Length.ejG:;-' _.- Width_ 4- `-V.._ Diameter________________ Depth --- - 4-!;.... Disposal Trench — Ido . .................... Width .................... Total Length .................... Total leaching area ---------;----------sq. ft. Seepage Pit No ......... ........... Diameter ..... (_........ Depth below inlet ---. �----------- Total leaching ar;*.- Other Distribution box (X� Dosing tarllf ( ) Percolation Test Results , Performed by. �`-tGY.'__GsS�................................... Date ........................................ Test Pit No. 1 ................minutes per inch Depth of Test Pit ----- `("____ Depth to ground water ... hn.-e_.--.__.__. Test Pit No. 2 ----------------minutes per inch Depth of Test Pit ----1`61------- Depth to ground water --- klof'�t�----_--_ (�1c.j L -2w• r.--------------------------------------------------------------(H`-!--`_------------.--.......................---------- - Descriptionof Soil -----------------------------1 -.n-ri-----------------------------------------------------------------------------------.._..------...------------.... --- ---------------------------------------------------------------------------------------------------------------------- asture of Repairs or Alterations — Answer when applicable. ................. 4 --- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Co — e undersigned further agrees not to place the, system in operation until a Certificate of Comp ' e s by the board of health. Sign-------------------------------------------------------------------------------------------------� -- � i 11 hh Application Approved Dat By --------------------------------------- --- ------------------------------------------------------------ .....�° �J Application Disapproved for the following reasons: ..... ....................... ...................................................................................................................................................... .......L -.7.1Permit No- ------------------- `..� �'-------. Issued ---------------f - q. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Dare Date Certtftrate of Grayltttne THIS 1,S -TO CERT Y, That thg I> dividual Sewage Disposal System constructed_( ) or Repaired by �J �'� - ------ -----------i- s - -- -- -------------------- LQstaller at---------------------t''-\--------.. ................. -A----•� /---' - �---- ...--------------------------------------- ------------------------------------------------------ has been installed in accordance with the provisions of TITLE 5 he State Environmental Code as desh n the application for Disposal Works Construction Permit No. I.l 1._" _r_.__ _. ___mac ....... dated ----------1 I.....I -�.-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ED AS A GUARANT E THE SYSTEM WILL fUNTION SATISFACTORY. �y Ins ector __.. DATE I - 1---------- p .............. i