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...... FzE;............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H TH �d
Appliratiou far Disposal
Application is hereby made for a Permit to Co struct (' or Repair ( ) an Individual Sewage Disposal
Syst a :
-__._ -
... _______l__ ... _ - ... ............ _y,_____ _ __ _ -------------
......._______.___^.--..... ...
L tion-A No.
caner Address
� Installer �/% Address
UType of Buildi Sie Lot............................Sq. feet
�-, Dwelling—No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( )
11
04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ____________________________ .. -- .- ------•----
W Design Flow___________________ ........ per person per day. Total daily flow"
----------- ._..__---__--._--gallons.
WSeptic Tank-Liquid capacity, gallons Length________________ Width------------.--- Diameter---------------- Deptll______._____---.
x Disposal�nch`-y o_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._._.�_____ Diameter_ _-__ Depth below inlet___.......... Total leaching area_IQ__d_A/sq. ft.
z Other Distribution box ( ) Dosing tank ( )
0-1 Percolation Test Results Performed by.......................................................................... Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.-_.____-_______-__.---.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to gr and water------------------------
a' _ --------- 9-- ------•--- ---- ..........-------------
O Description of Soil----- ___________
------ - -----------------
U ---------------------------------------------------------------,- ---------------------------------------------------------------------------------- - -------____.__------------------------------
W /� �' ...Ta------/�i� C ._f, f�voktS - -- ---'c- S E�'i .d/7-
V Nature of Repairs or Alterations—Answer when applicable.-.--_____-____--�Gz.'_73__-_._._ _/L
------------------------------------------------------------------------------------
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 board of health.
Signed
3. D to
----------
Application Approved By.....
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
....•-------•----------------•-•--------•--••----••-----••----------••-•----•--•--••--------••--•-------
-----------
Permit No- --------------------------------•••-------•---------_.. Issued-•---AY _ __
Date
TOWN OF BARNSTABLE
LOCATION n` l LL B A (f SEWAGE
VILLAGE CiEM'T urz V Q LL_6 ASSESSOR'S MAP & LOT � .-1 too
INSTALLER'S NAME & PHONE NO. �'j��� a L� � 1 3 tvZ— G6'(%
SEPTIC TANK CAPACITY t 60 C-) 6 A L -PlZECAS'f' bt- -1 tj N k
LEACHING FACILITY:(type)?,CCA5'T- LEAe-k dam' 1-(size) Q wq L
NO. OF BEDROOMS 3 UBLIC WATER
BUILDER OR OWNER T r-v U L H L Ga 1'I°1 A &3
DATE PERMIT ISSUED:_ ,!!� � F , l g 7 2
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
3 's n
} �
---•-- Flz$......ter......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE TH
/ /
Applirtation for Bhipagal Morkiilaaa rurtioaa eraati
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Syst _ a
...... ' — ...... •-••-L&14 ....................................................
y{/{ L cation aAd
I.. 4 ._ ...
--. caner Address "
... � --`--------- --•- .-•----------------------
- Installer Address
Q Type of Buildijn,� Size Lot----------------------------Sq. feet
V Dwelling�No. of Bedrooms.........:.. ..........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building -------------------------_ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
QOther fixtures ...............................................................................................................
W Design Flow. ................. .... __-_....gallons per person per day. Total daily flow_-.....-.-.--..-..------. ._.-....gallons.
WSeptic Tank Liquid capacity/t -gallons Length................ Width---------------- Diameter---...-_-----.-. Depth------------....
x Disposal-Trench—No. .................... Width.................... Total Length.................... Total leaching area.-_-.---.....�..-sq. ft.
Diameter. 411V... Depth below inlet--_ _1----..---.- Total leaching Seepage Pit No _ � .� g 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........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to
g r and water--..............-_......
..................t. .. -•- ---- ---- --------------- ----•-.-•-•_ . .............
0 1 , e
escrpt . � �w....
U --•-------•--•••---•-------------••---•••••----------•------•---••---•••----------------•--•--•----•-------•-••------------•--••---•-------•-------•-------------•--•••••---•--•---------------...-----
w
UNature of Repairs or Alterations=Answer when applicable--------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------=---------------------------------------------- ----------------------------------------------------
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 board of health.
Signed - •-------•------•---------------•----------- •--•----- D tee °�---
Application Approved By----- Fy'= ° ---•---------- �- _ � --�+ ----
Date
Application Disapproved for the following reasons------------------------------- /// ------------------------------- --------------------------------•---
Date,
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH. )
1.00.117.'"1............OF......... .... ..eg :...........
T� %Lpprtifiratr of Toutpliaaaarr
THIS I TO CERTIFY hat the Individual Sewage Disposal System constructed ( j or Repaired ( )
by----.-- LAY-----0 -------_--
icy+ rlj All
---------Ga
has been installed in accordance with the provisions of Article XI of,The State Sanitary Code as de cribed in the
application for Disposal Works Construction Permit No._--....�'... ......:.......... dated...---_.t % -----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME
SYSTEM WIFU TION SATIS ACTORY. {
DATE --------. Inspector . ' :.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F" HEALTH
...,. ...c�� �'' <.............OF.... `r; •. -. r - �°.............
P—t Jam"✓,,1
No......... FEE 4�---_--------
i��la�tt lvrk,� � a ��raar�ila�a l'raaai�
Permission Is ereby-granted = 1. ' ------ -------------------------------------------------- -
to Cons tic. or it ( ) n I ld* Iduef Seviage/,Dko ` Sys m
at No )��.a t _' �`� �. -1.�`..1 ` =- ---------------------------------- -------------
x; Street
as shown on the application for Disposal Worlcs Construction P m. No------ - ------ e -.-.a/C�/�Z........
. •••. ----- ---- --- -
Board of Healt
DATE.. K
FORM 1255-'..HOBBS & WARREN, INC.. PUBLISHERS - - - .
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tr �..