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S M E A D
KEEPING YOU ORGANIZED
No. 10334
2-153L
MADE IN USA
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3 ` TOWN OF B STABLE
LOCATION� 5 SEWAGE# f « ' (
VILLAGEt V l'kl ASSESSOR'S MAP&PARCEL
INSTAL LER'S NAME&PHONE NO.
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''.SEPTIC STANK CAPACITY
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�yt-EACI"NG FACILITY:(type) S '" 5s fie+ 'Q{ ';(size)
NO.OF BEDROOMS
OWNER It,Py
PERMIT DATE �.��� 1 .�, COMPLIANCE DATE: °g �Ala
Separatton`pistarice Between the:
Maximum"Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
¢ P.rivate Water Supply Well acid Leaching Facility(If any wells exist on
fi site or.within 200 feet.of leaching facility) Feet.
k Edge of Wetland and Leaching Facility(If any wetlands exist within a ';
' . 0' 300°feet of leaching facility) Feet'.
-FURNISHED BY.
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No. �.�i ' � Feer
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for BispoSaY 6pBtrut Construction Permit
\ Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No. j Q�ne Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 'I , S l iq\4 I CQ J, l 1 Oct Q
Installer's Name,Address,and Tel. o. e C't� Designer's Name,Address,and Tel.No.
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Type of Building:
Dwelling No:of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) W gpd Design flow provided N �/ gpd
.Plan Date Number of sheets 'Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs\or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.Signed Date •G • 2-1
Application Approved by ~y y Date
Application Disapproved by Date
for the following reasons
Permit No. D Date Issued t
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No. 1-Q Jac r. Fee .C3�
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.THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y
PUBLIC HEALTH DIVISION - TOWNdOF-BARNSTABLE, MASSACHUSETTS s'
.n. alpflcatlon for -MIsposal �&pstrm (Construction permit
\ Application for a Permit to Construct( ) Repair V"Upgrade( ) Abandon( ) ❑Complete System ❑✓ n�i dividual Components
Location Address or Lot No. 5*0&n '* f) Owner's Name,Address,and Tel.No. �;5.5� (C) ,
tt
Assessor's Map/Parcel ,i.AJ • (y'`1 on i,Q
M ,Installer's Name,Address,and Tel.N`o. e- C" 1�'c Designer's Name,Address,and Tel.No.
- ,
Type of Building:
Dwelling No.of Bedrooms 0 A. Lot Size sq.ft. Garbage Grinder
f '
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 4" gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ` ' Type of S.A.S.
Description'of Soil
.l
Nature of Repairs o r Alterations(Answer when applicable)
t
le
Date last inspected:
f.
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
v 'Compliance has been issued by this`Board of Health.
Signed � `Date 1'
.�
Application Approved by r yr , Date, t._ 11 _ 24,
Application Disapproved by `J Date
for the following reasons `
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Permit No. D Date Issued r�l )r 42
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by
at5, _g•, C has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2°'xf—LW• dated/./
Installer Designer
Designer , !n
#bedrooms Approved design flow !1 gpd
The issuance of this permit shall not be construed as a guarantee that the system will function_as-designed:
f l £
Date r� .�' FFF Inspector
. -----N ------------• -------------- -- -- -- -- - - - ---- --• - -- - ---- --- -----------------
o Fe
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -B_ARNSTABLE,MASSACHUSETTS
c. ;.Disposal � stem Construction Permit
�flr, � p
U Permission is hereby granted to Construct( ) Repair( �^+ Upgrade( ) Abandon
System located at ,l 7 c c,tom, ri t—• "i er,:��.,a....
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be co7.pleted within three years of the date of this permit.
Date c�l�It z ( Approved b
i PP Y -
TOWN OF BARATABLE
LOCATION_ (� �nS'f J Q 0
SEWAGE# r.
VILLAGE l 0A ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. �4�
f c% CA
SEPTIC TANK CAPACITY ._ S >�
LEACHING FACILITY:(type) 42C IC �
to Pit (size)
NO.OF BEDROOMS t A p QoM 441
OWNER LP C _t \f (nl �C�h t_
PERMIT DATE: ( a 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)
Edge of Wetland and Leaching Facility(If any wetlands exist within Feet
300 feet of leaching facility)
Feet
FURNISHED BY
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