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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
AMMM 'TOWN OF BARNSTABLE
Permit to Construct or Repair f,<an Individual Sewage Disposal
System at:
Location-Address or Lot No.
Owner
Installer Address
Dwelling— No. of Bedr
Z Other Distribution box ( ) Dosing tank ( )
1.4
------------------------
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of & State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance ha n * s r e
Due
Date
---'—'--------'--------'-'---------------------'--'----' --'----------
Permit No --�� ��-�. -�- ��'��-----.- Issued --------------_- Due
Fss.. �?.... ..
»..
THE COMMONWEALTH OF MASSACHUSETTS �� G_ l`
BOARD OF HEALTH a
TOWN OF BARNSTABLE
i� ft 1i �t 1W -Di meal Work.6 Cnomitr to� � �� � nrf n rrrnttt
Application is hereby made for a Permit to Construct ( ) or Repair ( (i)�an Individual Sewage Disposal
System at: (,,
�+ --------------•-��•••. '=! f-`�` '----......w......................... --•---•---- ---------------------------- -- ----••---------- ----..............•.
Location.Address or Lot No.
........... _i-� �.Y......�T YI.t..D_.. r S c S!r:E' 'L_ "............................................................
Owner Address'
W emu . .� _ _Un s �O C�� �-7 r�� � -...
a ----------------------- ---• .._....•--
Instalter Address
UT Sype of Building Size Lot______________.............. q. feet
0-4 Dwelling—No. of Bedrooms._.a------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
' Other fixtures ..........:..................................................................................................
g .---..gallons per person per day. Total daily flow...-...r ............................gallons.
Design Flow..-----.��...�.----------•- � ��
I W Septic Tank—Liquid capacity 07 -gallons Length. .............. Width. �......... Diameter................. Depth................
x
Disposal Trench--No. ..................... Width.................... Total Length ................... Total leaching area....................sq. ft.
3 Seepage Pit No------/............ Diameter../�)---......... Depth below inlet... ......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed bY.......................................................................... Date........................................
1-4 Test Pit No. I................minutes per inch Depth of Test Pit...--............... Depth to ground water........................
(];4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+ ----------------------------------------------------------
••--------..... ---•----• ...-----.........------._..... -------
.............
ODescription of Soil........................................................................................................................................................................
' ...............•. ........ .....-_.................................................._.................-_.._.......... •-...................- L........._....._.._..-............._..__....................
U Nature of Repairs or Alteration —Answer when applicable-.-...S�f!�c5 a. ---- .! t + �-_ .-___.
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 been ' s ed-by-the-boar of health:
,.-� g. v,
Signed ................1.. ..... - ......................... ................................:......
Application Approved By ........ .�..'.^.�.`...�..�}.... ...}....� , .. ............................................................................ ....tom
e„7 Date
Application Disapproved for the following reasons: .................................................... ... . ................................ --..........---- .........
............... .... ................. ..........................................................................................................................-- ................................ ........................................
l Dare
PermitNo. ...... U/ Issued ..................................................... ....-..
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�ertifirate of CZomplian.ce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
.,A.. . e a.... .................................................................. . ..--.......... ..........
iat ........................... ... ....... .......1 w= ................. .- '... ...................................................... .....
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ... ....... dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................... .................................... Inspector .............................................a...................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No......,..y....�::._ �( FEE..... a.r:.........
�i��nsttl nr�� �un�tr�#inn �rrntit
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Permission is hereby granted....................... - ` -.--.------- ----
L�---•-•-•••-•---•-----•
to Construct ( ) or Repair- ( ) a�ndividual Sewage Disposal System
at No...................................
•................•-•---•• _ *n.A...,. _.....-��•-- .f'.�l...r------......
•---
street rr
as shown on the application for Disposal Works Construction Permit No.7Y726L4 Dated---- �-'...1..V.....
DATE 5.',l 7 ^ t y lJ Board of Health
..............................................................
FORM 36508 HOBBS&WARREN.MC.,PUBLISHERS