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A M � 6X SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �' x 7 E&:c =1S(size) 5 NO. OF BEDROOMS PRIVATE WELL O PUB—LOG WATER BUILDER OR OWNERS Q �j �� z,t; DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: /3- VARIANCE GRANTED: Yes No -� ;�17 C ASSESSORS MAP NO: ®® PARCEL NO: No....1r-.-_L.Q... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Uwvviial Marks Tomitrurtiun rrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System t: - - •• ..... m'�!� S�sPl�L i:.... J.' ..- ..........-- ...--•-•-' o t z� •.• Locatio Address ----------. � ............................... -----------------•-••••.----•..............------ _.................................--- /��•• Ow er Address Installer Address Q Type of Building Size Lot............................Sq. feet V� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e� yp of Building ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( ) Q Other fixtures ......... -----••-------•------------------------------••--------------•---------••------..._.....------ Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity.16D_0.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. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water......................... G� Test Pit No. 2................minutes per inch Depth of Test Pit---_................ Depth to ground water........................ 0 a --------------------------•--•----------•----------•--•----------------....-----••-••-------......................................................... Description of Soil...............................................................................------------------------------------------------------------------------------•--•------ W V .--------------------•--••-------------•--------...------------.....•-••-----------------......------------------------------------------------------------------.....---•------------••----•---------•-- W U Nature of Repairs or Alterations—Answer when applicable............. --------if ` I- ------•---------•--------------------------•---------------•------•-----•----•--------------••••-----------••--------------....-•--------•----•-------•--•---------•-••---•---------....__.......••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue Ay the board of health. Signed .. -'M!V ................Dace....................... Application Approved By .............. .. .. ....----..-..-....--------...----------------------------------------------------- ........ ..�Z----- S' Application Disapproved for the following reasons- ------ - ---------------- -------------------------- ---------------------------------------------------------------------- ----------------------- --------------- --- ---------- -------- ---------------------- .........-------- ..........---- ------...---------------- . ------------................... .................................... Date PermitNo. ........... -� "- -- --�............ ......... Issued .................- -- ------------- -------------- ------- Date pE: „ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE , pphration for Bi-spnna1 Vorkg Tonstrnrtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -- G � �t.....rp' ..��_ItL.C.... ............. c-�— Locatio Address f--Lo .......... f e� j••_ --r�!� *.�'d.�GtT,------------------------•-•-•-• --•--••-----•------------------•--•--•----------t-No--•---•-••---------•------•-•------....... Owner Address. a ....................... ...... P - ................................... ..------------------------=---...------------............................------.............------ Installer Address UType of Building Size Lot............................Sq. feet .—I Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid*capacity.. o&Q.gallons Length--------e.... 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. ft. Z Other Distribution box ( ) Dosing tank ( ) HI Percolation Test Results Performed bY---------------------=.................................................... Date........................................ 0-1 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_................ 9 ---------------------------------------------------•---•--------•--•----------.....----------•_....•......................................................... 0 Description of Soil......................................................... -----------------------------------••------------------------------------..........---- x U .......--•------------•--•-----•-•---------•••-------------•••._...-------------•••---------•--•-•••.....-------••-------------••-----•-----••-------••------------•-------..........--•.....--••--•---•- UW -----------------------------------------------------------------------•--••••------•-----•-•--------••---••-•------------•----•---•------•--•••-------•--•-----••••-•----••-•--•----------•--•••...... 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee�iissuedy/,bby he board of health. Signed .yam- --------------------------- .e. Date Application Approved BY � U ---------------------------------------------------------------------------------- ------ 3 is e6 Application Disapproved for the following reasons- ---------------------------------------------------I.................................................................--------....----- ................................... ................_-------------------------...............................................------------------------------------------------------------- ...............................-------- Date Permit No. .. / - -Q--... Issued .... ............ Date THE COMMONWEALTH OF MASSACHUSETTS 4 BOARD OF HEALTH TOWN OF BARNSTABLE C�er#ifi ate of C'Iantlaiianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired'( ) by ........ 1- Q1- - . .................................... ................................ .. ------------------..--..... ...............--------- ------ ------------ / Installer has been installed in accorfl?nce�tevisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..........?a--- --.-t ........ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. y.--'../.. .............................................. Inspector --------- ....: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qlJ TOWN OF BARNSTABLE // N o...... FEE..l.. ......... Disposal Works Onnntrurtion unfit Permission is hereby granted..........W.,. 1414 1_1� ------•--•----•-------------------•-•--------------.....------...-----.............-•----. to Construct ( )Pn/o�r��RepaSir,( ) an Individual Sewage Disposal System atat _� No. .�X1�5... tl�..-. ..... Street/9 C-_ `......................................... as shown on the application for Disposal Works Construction Permit No.._!`r1_-.1Q.__. Dated.......................................... ----��-------------------------------------------------------- DATE. Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS