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TOWN OF BARNSTABLE WATER POLLUTION CONTROL DEPARTMENT
9 APPLICATION FOR SEWERAGE PERMIT Permit NQ — 1878
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I •Kille-r.,....���x,�!._.�.Y....� ...�t....�5?CCl�l1.d.��....11..,:LFIa�bO.r...HOUSe.:.MOte1 � _.. _. . owner of the Estate hereby
Full Name
apply for a sewer connection from ....1.19....Q.r-pul....5.....a....HY............................... for the purpose of draining the following:
Street and No.
Water Closet ............ ._... Shower _. _. ..... ..............««... Urinal ..........._.......................--- Other ..........._«.«.«
Sink ................................ _ .. Lavatory Bowl ............... Dish Washer ......................... Other .._. ...... .« . «_... «««_
Bath Tub «.......... «.«. Set Tub ........................ Washing Machine ....:._.... Other
to the common sewer on .....Ocean St EXPIRES 7/11/8� Fixture Rate 0
....................................«.....». _ r
Street Meter Rate [
a. And 'the undersigned further agrees to strictly conform to the Laws and ordinances relating to sewers,
and to the rules and regulations that are now in force or may be adopted in relation thereto, and also to the
plumbing laws and ordinances so far as they relate thereto.
b. And the undersigned further agrees for himself, his heirs, devisees and assigns, that the said Water
Pollution Control Board shall have access at all reasonable hours to the said premises, to see that all the
laws, ordinances, rules and regulations relating to the sewer are complied with.
Owner's Signature « __...._ _.. _ . _ ......... �« _. _...«._.
Accepted _..... _._........_................... _._._ _..««....:......._ Addre _... ... «...« .._ . ..._ ««_ . .._._._._. ...._._.__. « ««_.«
Date �.
By __.« . ,/._..._..._/._...... _ 'Ageennt//A'ttorney
Contr c or s�Siignature
By ............._.............................................._....__._._ « ._....._..................._«_ __ Address _......
Water Pollution Control Board
White - Office Copy; Canary - Treatment Plant; Pink - Company; Goldenrod - Owner
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