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INITIATIVE
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE. "". ,.'
Applira#ion for Di-spasal Work.5 TomarUr,
Application is hereby made for a Permit to Construct ( ) or Repair (k-)"'an Individual Sewage Disposal
System at: I
..............................•. ---•--.. . .................................... ----...---._.........._......----•--••---------•--••-••--•-•--•--••--------._...........------__..
Lo ation-Address or Lot No.
- _ .........:0 r!{.s.°°--------------------------•----- ..........-_._..--------------------------- ...................
Ow er Address
� ----...._�C.�A_�..._._Gee��-�=�=�.............................•-----•-----•--- --•---...----------...-----•--•-•--•-•----....----•-•---......._._...---....--•-•-•--....---------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling 6 No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d 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..........._............
44 Test Pit No. 2................minutes per inch Depth of.Test Pit---_................ Depth to ground water........................
0 94 -•••--••-••---------••-•••-••-•---•------------•••---•----••••------•-•-------------•....•-•--_...--.........................................................
Description of Soil...............................................................................--------------------------------------••----------------------•••-••--•-._.....-•••--••-
x
V. -----------•--•--••-•-....--•-•--•----•-------•-----•--•-•-•------------------•-••---------•...--•-•-•-----•--•-----•-•-•-------•••••••----••--•••--•-•-•••-•--••••-•---------•----------•--•----•--•--
W
x --------•-••----------------•-----•••---------•---•••------•----•••••--- ---•--•-•••-•••-•--••••••-----•-•-•---•••----------•---------••-------••---•••-•--•--
U Nature of Repairs or Alterations—Answer when applicable___________________J- -1-11...3__-Zn_ r�1______.._._._-
-- -----------------------------------------------------•---------------.._._..-•----•••••••••---_----
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 as been issued
by the oa d of health.
Signed .-. --- -/..-'�% %/� I .. 1C ...
Dace
ApplicationApproved By -- -------- - - - --- - - --- - ..... . ----- ................................. -..--........-...-----...-...-......--
Dace
Application Disapproved f r the following reasons: ....................... ...................................................... ....................... . .............
- ------------ ---=--- --- -
�. Dace
PermitNo. ... .. ....... ... ..l! Issued -- -- ------..--...-..-----------------......----....-..-------
Dace
TOWN OF BARNSTABLE
LOCATION 27 SEWAGE #
VILLAGE C�/.(�rz 2v� Ilr ASSESSOR'S MAP & LOT J f 4 • d
INSTALLER'S NAME & PHONE NO. ODfoon-&n7oQv3-- ydB-565/O
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)J X"`72g% (size) 3
NO. OF BEDROOMS oZ PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: /0)/�/`�a
DATE COMPLIANCE ISSUED: � ,
VARIANCE GRANTED: Yes No
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45
54,DC- Fioob,,X�-1
----_
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B RD-WIHEALTH
TOWN OF BARNSTABLE
Cerlifirate of Tantlatianric
THIS IS T T hat the Individual Sewage Disposal System constructed or Repaired
V-150Q SUM-P47>.......................... -- --------------------------1-------- - ---------- X)
by ..... ..... ----------------------...................
ns
at .........I... ...a-'V6.... .......................................... .................
&Dfi- ....LC.................
T---i----------
has been installed in,-accordance with the provisions of TITL of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -jo------ ------ dated ................................................
!!7�...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................j-Q------ Inspector ................... ...................................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No....../- .......... FEE.—.. ...
Rapolmil 2 -
Permission is hereby grante ��.Oj.........0........ ..................................................................
to Construe or a -ar.n div i .1 uaI Sew
I pjs System
------- -V. .........................
Stree
as shown on the application for Disposal Works Construction D
-.�----f�. ......�.___�_..:.
Z",
. .............. ...........
I Board of Health`
DATE.-1.11'/04..'V- ------------------------------- ----------------
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
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�3No.. .4._....... FEB ..... .........
THE COMMONWEALTH bF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Bispv,ia1 Works Coo r r tong Trutt
Application is hereby made for a Permit to Construct ( ) or Repair (li an Individual Sewage Disposal
System at:
.........................._ '.r1.:.. / c T -•••...---......------••-••--•••••----•-.... ...---••---••••......•••............•••••.
.............................................................T
LoEation-Address or Lot No.
30HP{s° �
Owner Address
----------------------------•-••-•-•••••-• --••-•----••-•-•• ......--•...------•----•---•••-•••••.......
Installer Address
Type of Building a Size Lot............................Sq. feet
a 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.
WSeptic 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. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY--------------------------------------:................................... Date........................................
Test Pit No. I................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 ground water........................
a .............................................................-••••-----.....••-••----------••-..............................................................
CDescription of Soil........................................................................................................................................................................
W _
UNature of Repairs or Alterations—Answer when applicable---------------------/-_4.fl:'9---3.� ........................
-----------------------------------•------------------------------•--------------------•------------•--•-••-•---•-------------••-----•---•---•••---•---------•----•-••--••.......--•••••----....-••-•---
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 as been issued by the oayd of health.
•g
Sl ned ...! .----- ..... ------------- ---- -���
�, Date
L
pplication Approved BY �!i /> :/� - -'> �7. JC_ (................
Dare
pplication Disapproved f r the following reasons:
---------------- .....--- -------------------------------------.....-..................-------------------------- -------------_--...-------------.:---
j) Date
Permit No. ---.,...../.�... ......t_/ .�......... Issued -----------------------------------
........
Date
THE COMMONWEALTH OF MASSACHUSETTS