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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliraffou for Uiiplaiial Works Toustrndiun amit
Application is hereby made for a Permit to Construct ( ) or Repair ( —Jan Individual Sewage Disposal
System at
• ............ _....... �. .1 --.....:. .V.. .....__. - c a v e ...= --•� p-✓�9-j1e,
Locatio -Address or Lot No.l
Ownerr. s! --•--•.• �� • r_..5..�..._..
Installer Address
Type of Building Size Lot....._______________________Sq. feet
U Dwelling—No. of Bedrooms___..3..................... .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
a' Other fixtures ............................
w Design Flow........�__� ---------- �/-//-��---gallons per person per day. Total lily flow.......�13.�_�---------------.gallons.
WSeptic Tank/—Liquid caLpty�j—gallons L%ngth_�L�.._._.. Width.._J._------- Diameter________________ Depth................
x Disposal Trench—No. ___ .0 _ Width.1.0.......... 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........................................
aTest Pit No. I................minutes per inch Depth of Test Pit------------........ Depth to ground water........................
4A Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ...................=------...............................................................................................................................----
.
0 Description of Soil........... ----------•------•-••------•-------------------------...----•------------.
x
w
U Nature of Repairs or Alterations Answ when applicablle, '!�-,`mil! �_�....__I_ ._G"Sr....... 4
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 1
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 Com fiance has be n ' oa of health.
�� ........~
Signed ......... ... ..... ..... .. -- -------- ------------------- ..--- ------t q Date �
ApplicationApproved By -------------------------------------------------------------------- ----------------- --------------------- ..... ---- ......
Dare
Application Disapproved for the following reasons: ........ ..............................------. . .- ��
LY.
...... ........................................................................................'---'-----.-...................................................
---------------------- - - -- -..-------- ----- .-.--........-..-------. ..........-..-..Date..-.-.---------.-. :E
Dare
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Permit No. �- ----------------------------------- ---- Issued ------------------------------------------....--------------
Dare
6-1
AIO.._._...... • - i FEE..-��
4- THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
F TOWN OF BARNSTABLE
App iration for Disposal Workii Tnnstrurtion t1trutit
Application is hereby made for a Permit to Construct ( ) or Repair ( —)an Individual Sewage Disposal
System at:
... .._.....2 V 1.1�- f V --......
............... .. . ... --• .......
Address��V .\ S � Lot No.'
Owner n_ a ,/L ._ A dt`es's(_ , j
-�- - -- •....
Installer Address
UType of Building 3 P ( ) Size Lot...---.__._... feet
DwellingNo. of Bedrooms--------................................ Showers — ( )
a Other—Type T e of Building ____-___•___••_•__•-____---• No. of ersons__________________
Expansion Attic Garbage Grinder
� yp g p ( ) Cafeteria
Otherfixtures --------------------------••--------•--•--•--------------•-•••--•----•----•-•-••-••-----•--•-•-••--•-••-••••--••-•-••••......-•••-•-•-••-••••_••-•--
W Design Flow......... .. .....__...r.__ -gallons per person per day. Total drily flow......��.��_�................gallons.
W Septic Tank-t Liquid ca�ajcity. �—gallons L ength_/ ...... Width..._�_......_ Diameter________________ Depth__,............
.
x Disposal Trench—No.! !. !S.-�Width... Total Length----06P...... 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water---__-_______-________-.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.....................
----------------------------------•----.....--•------------•--....------------.....-----•---•---•-•-........------••-•••-----•-•-•--••-•---•-•----------•-•-.
0 Description of Soil.................................................................................. --------------------------•-------------------------------------------------•-
x
U .-----------------------•---------•-•----------------•-••-----------•--...-•-•----•-------•-------------....-•----------------------•------------•-------•--------------------------------------------••.
-- ----------------------------------
U Nature of Repairs or Alterations—Answer when a llcable tiL 1 ( �/ U �
�3 Z- ......................................................` .......................cJ ` _f G%lC�,c cs t o✓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
f as been issued-by-th-e board of health.._
Y P P
system In operation until a Certificate o Com lia ce has -� ------------- ------------ --- ------------------
Application `1 SI ned�- ---- --�---- ---------------------------------�`------�--`�-_-----y---- -- �--Date
A roved B ... X - - -
Pp Y - --
A lication`Disa roved or the ollowan reason _- =�:� r" �'�'' fs
PP PP f f g --
------------------------ --------------------------------- --- -- ---------- ----------- --- --------------------
�ate.
PermitNo. ------------ --c3C 7---------- -- Issued .......................--------------- -------
.. -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#tftctt#e of C antlatiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by- ---------------!�!..tA��f L-�.���...-..5��..'L_C .........--------------...---------..-...-------
Installer ,,.,
at r� ��'\ I F. .. _ ✓- �f --------------- C. w cl...........l
tC
-----------------------------
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. ...;i....--." _
----`- -------------- dated ----/-!•z ----- -------....----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------------------------/r /.-/�
Inspector ....c ------------------------------------------------
THE
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�f ��� TOWN OF BARNSTABLE F,
NO......................... f� FEE:- ................ °
Disposal Works TWntritrtinn Virmit''
Permission is hereby granted............. ............( .......... .. ... :1 `r
to Construct ( ) or Repair ( C)-•ari Individual Sewage Disposal System
at No................`. � J'
Street
as shown on the application for Disposal Works Construction Permit No..%....... Dated_ ....................................
�� � Board of Health
DATE.. �/1 -•------ -
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
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