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RCA
S M E A D
KEEPING YOU ORGANIZED
No. 12534
2-153LOR j
�� MIN.RECYCLED
INITIATIVE CONTENTION
certieediterscuraep POST-CONSUMER®
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MADE IN USA
M ORGANI7,Ii-DAT SMFAD.Co►u
TO" BARNSTABLE 76'
LOCATION �S t SEWAGE#ft-
VILLAGE etd eelVlll ASSESSOR'S MAP&LOT a yLO•®D;
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
.�CfgGLi / f'
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER Al r�
PERMIT DATE: -129 /p� OMPLIANCE DATE:
a
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet'
Private Wgiter Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet n
Edge of Wetland and Leaching Facility(If"any:wetlands exist
within 300 feet of leaching;facility) Feet
Furnished by
l p
/UPS
A
TOWN OF BARNSTABL.E
LOCATION4o7-/7 SEWAGE
VILLAGECF,z-7 ^t V t ! r ASSESSOR'S MAP & LOT_ZY —
INSTALLER'S NAME tCz PHONE NO.A4 Ce"I � 7 S
SEP'nC TANK CAPACITY 10 0 0 6/9
LEACHING FACILITY:(type) /"/T (size)
NO. OF BEDROOMS - PRIVATE WELL OR PUBLIC WATER
BU[LDER R ��✓i��l �� � O�iTG `jam �/ _.
DATE PERMIT ISSUED:
DATE COZLPLIANCE ISSUED-
VARIANCE GRANTED: Yes .4"/ No
r' 9�
ASSESSORS MAP NO:
No----- PARCEL N0: doe ] Fss......,�,�.-........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...... ........ ------- ---.....OF................................_.......-------------
Appliration for Uin#usa1 iUurkg Tantitrurthitt rantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at:
/' Location-Address 'p `/ s r Lot No.
,� J ,
.._....h.vl.:=. 1 ........ �� i............................... lf- _4���i�8 e O G:__._._..._.1 '
W Owner Address
a ..........
Installer Address
Type of Building Size ... __.._._Sq. feet
Dwelling—No. of Bedrooms________________ .....................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building _______ No. of
a YP g --------------------• -------. ---------Persons -•-----------------Showers ( ) — Cafeteria ( )
d Other fixtures -----••-------•--•-••-••--------•---••••-
Design Flow................................. _��_gallons per person ;r day. Total dailyflow._ .___._.._-______._.__.____.... Ions:
' / a / N
W
WSeptic Tank—Liquid capacity-/�V_gallons Length----------- Width___ _ ___. Diameter._._--........Depth__4_V_ __.
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________ _____ Diameter.__._. Depth below inlet__-_,=�.... Total leaching area_9®_i$.....sq. ft.
Z Other Distribution box (V l Dosing tank ( )
aPercolation Test Results Performed b ---W;4n..< 1 __ _ ....... Date... ��
Test Pit No. 1.....Xr......minutes per inch Depth of Test Pit..../Z% Depth to ground water________________________
44 Test Pit No. 2........2 -_minutes per inch Depth of Test Pit...6Z Depth to ground water________________________
P4 •-•---•----•-•-----••••-•---•••• ...................... ......... -------..
Description of Soil--_� -_ ____.55..1 • +_" !C . ! _-_'.-St� S_----�6�Ki __._/e'__'__..----
W
U Nature 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 i I'1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss_u b ke boar heal ,(
Signed....` .....lr :... �,f.��`�
. / Date
Application Approved BY -•-. .-c_�- ---_.S!. _..
Date
Application Disapproved for the following reasons:--.............................................................................................................
--------------•-••--•------------•-------••----------------------•-------.....----------•----..................--------------------- ---------------------------------------------------------•--------
Date
Permit No........ •s--'---5_•3c�--------------•-------- Issued............................ ---•----••-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
cY2 c ail,.....O F .............f - .H..k `�y�... ....................................
vErrtifiratr of Toutplitturr
THIS IST""OCERTIFY, That the Individual Sewage Disposal System constructed (e or Repaired ( )
by -......�/� '" ---------------•--•--_____-----------••-----•-------------------___-----
at..... �F7`
------- � �a-•----------------------------------------•-•--•-------------
has been installed in accordance with the provisions of TITI f ofThe State Sanitary Code as described in the
application for Disposal Works Construction Permit No._______._�3'------J.'�,1_2....... dated________________________________________________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
i
THE COMMONWEALTF`f�CF MASSACHUSETTS
BOARD OF HEALTH
OF.........................................................................................
fir�ttion for Disposal Works Tonstrnrtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
�a/
Location-Address / .. v .yE
.?.Z.f..�-........�?-Li��it//, l.�,z.. C.......
Owner Address
W ............... .................. .........•---....•-----........__....._........_••--......_........•......._............._._.....
a Installer
Address
dType of Building Size Lot `.a J._.......Sq. feet
U Dwelling—No. of Bedrooms................ _--___-----_---__-Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............ No. of persons............................ Showers ( ) — Cafeteria ( )
Q+ Other fixtures •.............••••......---•••-- -
W Design Flow.................................��`:n•_gallons per person L)er day. Total daily flow._Z ------------------------------gallons.
WSeptic Tank—Liquid capacity,/_/- r,,2.gallons Length........ ..... Width...f�L' y_- Diameter-_._.---------- Depth.A_'--""_..
x Disposal Trench—No..................... Width.................... Total Length..:................. Total leaching area....................sq. ft.
Seepage Pit No------------- ----- Diameter......ZC1......_. Depth below inlet.... Total leaching area. �?.Q._....sq. ft.
Z Other Distribution box (✓} Dosing tank ( )
'—' Percolation Test Results Performed by__ `. -_ !=.. w!' �' "`' -------- Date____��'. v: a"d....--.
1.4
Test Pit No. l..... -----minutes per inch Depth of Test Pit.... z_Wiz_ Depth to ground water-------- �-........
Test Pit No. 2........7-..minutes per inch Depth of Test Pit---!Z_ Depth to ground water....._...'".."..........
0 Description of Soil-- %v.'' ` ..f?.G� ��.' �K_ %4// ..- ' '" '`' - `a ..'_ '.!a.'! c.f!' 7 .......
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 TITLss 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ue by the board of lth.
,/�.. �...
mate
Application Approved By-----------. ....... J..i. -~r`---------------------------- .....................Daa- -te----------••---
Application Disapproved for the following reasons--------------------------------------------------------------------------------••-----------------------------------•---•---••-•--••-••--•--•••-----------••-••----•----•--•-•--•••--.....
....--------•------•••-----•-•--•--••--•--•-••••-----•--••--------•-•----••-----------------•---------•--•••-•-----•-...•----•
GG Date
PermitNo....... ...... ----------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/`
Tntifiratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,,<) or Repaired ( )
•---....•----...---•................ ..•••-•-•--•••-••-----••••-------•-•-•--•-----•--••---------•......_....._..•-••-----------•••----....•••---......-•-••------•......••--....------
by_._....__.. 1ps 311er
at (,ter.z ` �`� --•-•-•V L:?_� � h �.... -•----••-•-• ................................................
been installed in accordance with the provisions of TITLE ` oThe State Sanitary Code as described in the
application for Disposal Works Construction Permit No-----._-�F�. `�.�._7....... dated___--------------------_----_----------------.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........1...C, ..G./r:.1...........0F...... -,-c a.a.4 '} ................................... FEE... 5...........
No..!J.11.......
Disposal Works Tonotrnrtion rrmit
Permissionis hereby granted.........................................................••----••-•--------•-••-...-••----••--•---•••-•-•--•••••-•...........................
to Construct ( or Repair ( ) an Individual eve=age Di�posal S tem
v ply, >r��,,
atNo.......... l ---......rJ `...:�.....----�----------- ......... ..................-`f--
Street U
as shown on the application for Disposal Works Construction Permit N _��"��� Dated..........................................
Board of Health
DATE---------------�..............................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
t o 16
114.99
I I 53.1 1=6 4 4
i { y rpz = 392 6pd
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' 112700
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Sate 9-7-88 C-i,t. gI ow 220 p,
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204 y
Capacity 392 c�.p,
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