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SUSTAINABLE
FORESTRY
INITIATIVE
I c affibusourcina
I �a
ro
t All ION SWAGE PERMIT NO.
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VI,LLAGE
/76 - �a
I N S U LLE,R'S NAME ADDRESS
R U OR OWNER
DATE PERMIT ISSUED Cl /�
DAT E COMPLIANCE ISSUED ��.
h.
TOWN OF BARNSTABLE
l!,UCATION 19 ��p pd Ge k tr�d t It SEWAGE# 037 - .13 0
VILLAGE Cie r%.4t r v i h� — ASSESSOR'S MAP&PARCEL 110 ' a4
INSTALLER'S NAME&PHONE NO. Can e w a p C YV
SEPTIC TANK CAPACITY /SU 0 14 10
LEACHING FACILITY:(type) (J-c t S-�vo e. (size) 2 u x 3 y
NO. OF BEDROOMS
OWNER wta J rOL lCc
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility) feet
Edge of Wetland and L-aching Facility(if any wetlands exist
within 300 feet of leaching:facility). feet
FURNISHED
33S-
Q�
1
TOWN OF BARNSTABLE
SEWAGE #
N L:GE -?e-—4, ��r y� p ASSESSOR'S Nr & LOT
iNSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
I,EACHING FACILITY: (type)
NO.OF BEDROOMS 1(
BUILDER OR OWNER S Tl
PERMITDATE: —COMP&NCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
7.O'W.o ..........OF......
Allpfira#ion for Uiipnsa1 Workii Tomitrurttun Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
P
----------------------------------- ---- ----------------------------------------------
.�� L a Ad r ss ' or Lot No.
�t .ate}r..................... .................................................................................................
...41Q- -
i—� w r sr Address
a .... _--�-----1�!��.1.��p ....?.-_.�.1�.......b• -------------------- ...........................................
Installer Address
U "Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons....................:....... Showers — Cafeteria
a' 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..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
•-' Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
- --------
O Description of Soil----------- iL ? f
x
V .....•-•-••-•••---••••---•----••-•••••••--•••-•-••-------••---•---•-•-•--•----•--••-••-•-••-•--------••••--••-•--•--•-•-•---••-••-•--•---••-•---••-••--•-••••••••-••••---•-•-----•--••--•--•.._..._..•...
W •--•--•-•-------•------------------•------•-•-•-•••-----•----------•-•--••-•...._...-••-•--••••-••-------------------------
- --------------- -- -----
- -
U Nature of Repairs or Alterations—Answer when applicable._.....__.4..."Z0.............................................................
.............................--•-•------•-•-•--••-•--••--•--•-----••-•--•-•••••----•-••--------------•-•-•--•-•--------•--•- ----•--••----•-••---•----•-------•-•-----•--•---•--•----•-.._.............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued b the oard of health. /
Application Approved BY -----•---•-- --------------
1 �1 X-..............
Application Disapproved for e f of ng reasons:......................................................
........................................................................................................................................
PermitNo.........................................................
_'.�Ncq..................... ......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................OF....... .7,7.........M..................................... .............. ..........
for Mipa0al Woaks 'Tumitrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
.................................................. ..................... .................................................................................................
Location-Address or Lot No.
................................. .. ....4 -1'A/
............... .. ............................... --------------------------- ............. ...............................................
Owner 7 Address
................................................................................................... ......................................7...........................................................
Installer Address
Type of Building Size Lot..:.........................Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
a4 Other—Type of Building -------------_--_---_- No. of persons.,........................... Showers Cafeteria
P-1 Other fixtures .................................................... ..................................................................................................
Design Flow.............................................gallons per person per day. Total daily flow..-,.........................................gallons.
P41 Septic Tank—Liquid capacity............gallons Length................ Width.__....-........ Diameter-_._--__-______ Depth................
Disposal Trench—No..................... Width. .. Total Length.................... Total leaching area.....................sq. ft.
Seepage Pit No..................... Diameter................... Depth below inlet.................... Total leaching area..................sq. f t.
Z Other Distribution,box ( ) Dosing tank ( )
Percolation Test Results Performed by------------------------................................................. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
114 Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water.....:_.._.........._._.
P1 .............................................................................................................................................................
0 Description,of Soil................... .......A...............................................................................................................................
x
U ...............................................................................................w.........................................................................................................
.......................................................................................................................................................................................................
:3�
U Nature of Repairs or Alterations—Answer when applicable_____:-_j��. -41— ...........
............................................
........................................................................................................................................................................ ..............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 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,board of health.4
S e .................
...................................................................... ......
ApplicationApproved.By...................... .................................................................... .... ..........
Application Disapproved for- e fol �ng reasons:..............................................................\-,
---------------------------------------------
........................................................................................................................................................................................................
Date
PermitNo........................................................ Issued.........!.............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF............................................. .........................................................................
f T rfifiratr of,T mpliatta%Ur W11
THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by.....:t.................................................................................................................................................................I............................
!I I- Installers
A li " / . -'
at.......................... ........................_.e.....................f...........................................................................
has been instilled in accordance with the provisions of TIT 5 TV tate Sanitary- o C_/as bed in the
:�-_.
application for Disposal Works Construction Permit No.402..--------- ----------- dated--.. ... ......................
THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A,GUARANTEE THAT THE
/E
SYSTEM WIL)e F)JNCTION SATISFACTORY.
DATE.1///ZZ/V____1------------------------7--------------------------- Inspector........ ....... ..............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
................................
......... ............OF.......
No ?3
........ FEE........................
ve
Permission is hereby granted.... ....................................
.......................................................................................
to Construct (,,) or Repair I-rian Individual,Sewage Disposal System
...... .........-
------------------ ------- ------- .............. .... ......................................................................................
Street
he app io Mr as shown on t:/cati n for Disposal Works Construction Permit- .. ................. Dated..........................................
...............................................................................................
11 Board of Health
DATE.....................7..........................................................
FORM 1255 HoeSs WARREN. 1 NC PUBLISHERS