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Sob / � 3d
TOWN OF BARNSTABLE5�6
LOCATION ��� �� SEWAGE # 7- 3 7
VILLAGE �� ASSESSOR'S MAP & LOT 3 0 3.2
INSTALLER'S NAME & PHONE NO /2�
AM
Ilk I
SEPTIC TANK CAPACITY Uy
LEACHING FACILITY:(type)
NO. OF BEDROOMS2--PRIVATE WELL OR PUBLIC WATER. d
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED: G - 2 g
VARIANCE GRANTED: Yes No ��
v 0
b
ASSESSORS MAP N0:
No. 3�f PARCEL NO: ,j�9� FF,.B 4,...aa......L2SD.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
- .'ZoWn:.......................OF.....115-axbat.able-.--------------------------.----------------------
Appliratinn for Uhipoii al Works Tonstrnrtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.....3.7... •- g........ ......•---•-------..._.........---•-•-----....._
Location.Address or Lot No.
Pon_tious
---•--•..............._.•......----...-•----...--•---•-------••-----•--•-•-••--•---......•....... ..........--.....................................................................................
�x Owner Address
.......................................................... --...............----•--•---•----•----
Installer Address
Type of Build' Size Lot............................Sq. feet
V Dwelling NO. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
Q' Other fixtures --___-______•____________________
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ......................................................... ....................................................................................
ODescription of Soil------ ---------------•----•------------••-------------------------------------------------------------------------....---------..
U ---•-------------------------------•--......--------•-------------------------------.....-----•-----------•--------- ----•----•-----------------------•-----------------------------------------------
..
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 1 i': :,».
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance jhasbeeissued b th o� of health.
Sign ! 6/9,/Date
ApplicationApproved By------------•• �--- -----------•-•--•-•-- ........................................
Date
Application Disapproved for the following reasons:..............................................................................................................
-•------------•-----------------------------•--•---••--------------------..--.........-----•-------_.......----------------------------•------•-------•-•--------•-•-•------------._. ......--------
Da
—
Permit No.---- .................------ Issued..------------------•---•-•
Date
.37i( FIzs- ]
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..OF • r t 1.'
Appliration for Bhipvii al Works Tonstrnrthin 11nmit
Application is hereby made for a Permit to Construct ( ) or Repair (. ) an Individual Sewage Disposal
System at:
tr t
.,
Location-Address or Lot No.
Owner Address
w i .•
Installer Address
UType of Building Size Lot............:...............Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ----------------------------------------------
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
GG Septic 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
(X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---______-_.___---_____-
Pa' --•--------•-----------•--••-•----•..........................•-•----------------•--•--------•---•-•-........................................................
0 Description of Soil..........==1 .......='�e I............................•--------•---•-••--•-•-•------------------•-•---------•---------------•--•-•-------••-•-------•--
x
w
UNature of Repairs or Alterations—Answer when applicable__ ....... _:_:: =. I..
Agreement:
The undersigned.agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of Ti'1 t, ;
p `}of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed---.... .......................................... ................
Date
AppliPP PP Y
cation Approved B �--�- t�Y'—�� '�' ................... -------•------
^� Date
Application Disapproved for the following reasons--------------------------•-•---•----•---------------------•---•-------------•--•---------------•......----••---
......................................•...•-•--•••--•--•--------••••-••-...-•--------------••----•.....------•-----••••••-•-----•••----•••-•••-•••-------•---•--------••••---•••-----••--••--•••••-----
ec�� Date
PermitNo..... 17••I......----•-----•_..... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ...........................O F...................... ._,:.t............`..........................................
Tntifiratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by------i - .___.- c o ---L F r
7 f F c,
Installer
at.......:.____....a_.._]_C , . C_ -t ..r ... :L
has been installed in accordance with the provisions of Ti l IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. -_._ ........... dated-_...................._-----_-__--__-_-____-_•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE 7 Inspector........
• ''."""' -•---•_____________••----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r.
OF......., ..... ........_..
�i��rr��l ork� �on��rion rrmi#
.. r e r•.' F. ri1, '
Permission is hereby granted___ a r%....'..°.`..'..::_......' .:.._.........
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
� a
at 1V o:'�............. '...............__....__.............._........._.._______._....................._.._...._.................._._..........._.........._.
...........................................
Street
as shown on the application for Disposal Works Construction Permit NoC7`.22���__• Dated..........................................
-'-'`'"ti`.""`"` ---------•-.------••-•-•---:.
Board Health ,�
DAB'E...................-•..................•-•••-••-••-••-•.........---•---•-...••- of
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS