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TOWN OF BARNSTABLE
LOCATION 49�5-,-'21AJ�fA.190P / 6 SEWAGE #
VILLAGE�/ °`�4 ASSESSOR'S MAP & LOT,::P57-67S
h
INSTALLER'S NAME & PHONE NO.
P
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER
BUILDER O OWN
DATE PERMIT ISSUED: Cam`/C1- at I OY 5' -_
DATE COMPLIANCE ISSUED: W _
VARIANCE GRANTED: Yes No /
e
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A
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ASSESSORS MAP NO: � -
'" PARCEL NO: Q Z
No...J3::_Q'a Fps�d.-.�.....
THE COMMONWEALTH OF MASSACHUSETTS "`
BOAR® OF HEALTH
3arnstabie conservation Depart TOWN OF BARNSTABLE
-2 it M nr ffispvsal Works Tomitrnrtion .ernti#
,Application is hereby made for a Permit to Construct ( ) or Repair (iK an Individual Sewage Disposal
System at-
, .� Q d�Q J 2 .............. Nr d
• - ........ - .................
- Location-Address t No
44
..... .. .......................................................... .--..... = ''¢' ' .....................................
/��, iwner A� Q� *1� Addrep / o
-•-- . ..__.,.[.•.a...(.%----------------------------------------------------------`......------. ............................................................•...............--------........----
Installer Address
U Type of Building Size Lot_-<=A9 Sq. feet
�., Dwelling—No. of Bedrooms................. ...........___.__.Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—Type of BuildingNo. of persons....................... Showers
� ------------------------------ P ----- (---)--- Cafeteria.( )
Otherfixtures ----------------------------••-•-------•---------------------•------------.
W Design Flow..................... ..............gallons per person per.day. Total daily flow............0-45� ....................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../4__........ Depth below inlet...._.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-. Percolation Test Results Performed by.........................................-------------------------------- Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-__-__-__:-_--------_-.
0:, Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................
W•---•----------------------------------------------•--------------......--------•---............----.........................................................
0 Description of Soil..............................................................................................................
W
V ..............•---•-•--••••-----•---•----------....-•--•---•--•--•-----------------•-----•-----•---------------------•-------•-------•--•••-------------•--=•------•-------------•-•-••-------•---------
W
x ------------------------------------------------------------------•--•---------- ----------•----------------•-----------------------•------••----------------••--•--•••---•--•---•------•--•••••--•.....
U . Nature of Repairs or Alterations—Answer when applic ble.�' __ Yu 65e4577!`4c._. cos-"._S LS
..........iaao.
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 has ee issu and o health.
Signed .-------------- -- ------------------- --- ------------------- --•---------- -- ----V� V� �
Da[e
Application Approved By ----------; 'u'`------- �--- ------------------------------------------------------------------ ..
Date
Application Disapproved for the following reasons- ----------------- ----------------------------------------------------------................. -----------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=---------------=--------- ......................................
Permit No. ,F 'C) Issued .........................................................Dare
Date
THE COMMONWEALTH OF MASSACHUSETTS R,
3 - -80'A'RD -OF HEALTH
TOWN OF BARNSTABLE
'Vlirtt Ilan for Disposal Works Tnnitrnrfiun Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (,/>� an Individual Sewage Disposal
System at:
.....� ................................. ... 2 ------------------- - ' 1�Vi ..-•----
,�a, r S Location Address �/N_C&J� ^ oyLot No.
--------------------- - (......... ............-- ..............
--------...e! •�-�N -......
Owner Add
.-
a --
Installer Address
UType of Building Size Lot._ Q�. .....Sq. feet
-. Dwelling—No. of Bedrooms..................v�..................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----------------------------------•---------------•----••----------•----••-••--••---------------•------•-••......-•--•-
WDesign Flow......................��.......•...gallons per person per day. Total daily flow.._.........c�-,��._........._.......gallons.
9 Septic Tank—Liquid capacity/ ..gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
.
x
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. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.....................
a •-•--•-•........................•••••••-=-•-••••-•-•------••-•••---•-•-••-•-•.........------••...............................................................
0 Description of Soil...............................................................................-•-••---------------••-•--••---------•-•••••---------------......••••••......----•---•-
W
------------------------------------------------------- --------------------------------•---------------------------------------------------------------------------------•••. •-•-•-.................
U Nature of Repairs or Alterations—Answer when
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 has Ike issu bhe ward o health.
S�
Signed. -- -- -.. .... --------------- --- --- ---- ------ ----- -- --- ------- ----- -----�/��
Date
ApplicationApproved By ------------ - .n-. -------------------------------------------------------------------- ....-- Date
Application
Application Disapproved for the following reasons- -------------------------- ----------------------------------------- ----------------------- ...............-------------------
-------------------------------------- ..................--------------------
Date
PermitNo. ..--- D._------_--------------_ Issued ............................................................-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(-lertifi a e of Tantlatiart e
THIS IS TO CERTIFY,at the ndividual Sewage Dis osaI System constructed ( ) or Repaired ( )
by--------------------------..............--------- ..-..................OG®77 o
------------------------------------------------------------------------------- --
Installer
at ..----...... 21!cI,
aizp..... ..., ------ (5'....
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. ....... c� .--../ ------------- dated .-...........................-.....-.-..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...............................................i' U1 ----------------------------- Inspector . - �^ •t..-....------------------------ .......... ...---------
/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLEQ
No..... ,-I FEE.... ....
Disposal Works TIMInstrudion Prrutit
Permission is hereby granted..........................
to Construct ( ) or Repair (X� an Indi idual Sewage Disposal System
at No... r ---•- /! cVdd ---.... _ �tliV t�
Street �
as shown on the application for Disposal Works Construction Permit N���/.. d.. Dated..........................................
------------------------••. -•••-----•-••----------------•-••-•-•-••-•........................._
DATE. Board of Health
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS