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TOWN OF BARNSTABLE G vv
LOCATION� �� 6 12 J SEWAGE #
VILLAGE 1'1/S A ESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE
SEPTIC TANK CAPACITY 1600 /
LEACHING FACILITY:(type)
(size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: i7
DATE COZIPLIANCE ISSUED:" 1O
VARIANCE GRANTED: Yes No �
O�
G
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Fss......., ..Q...�—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL "
. ...TO�•�-�.-.oF..� 2�41?c5 4.. _.......
Appliratiun for 11ispuiittl Works (filustrudion 1hrntit
Application is hereby made for a Permit to Construct ( ° ) or Repair ( "�ndividual Sewage Disposal
System at:
►��_/� ....(� ••L cation-Addres or Lot No.
- --•-- ..................C5-�_:•__•^`.,,�...............•----.........-•---•---F..._..-._...
Owner
.—:'h `'✓ rL- 1►�w:_�1�1 Address
' ..............................................
Installer ddress
Type of Building Size Lot...........................Sq. feet
�..� Dwelling—No. of Bedrooms--___�----------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g --------•................... p ( ) — Cafeteria. ( )
Othe�xt s ........................................................••-....-•-••--••-`•= �r '• .
...........
WDesign Flow................ .......................gallons per person per.day. Total daily flow....... .........................gallons.
WSeptic Tank—Liquid capacity............gallons ' Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.........:........... Width.................... Total Length..................... Total leaching area....................sq. ft.
3 Seepage Pit No.......L............ Diameter....U .—_..... Depth below inlet.... _........... Total•leaching area...........:......sq. ft..
Z Other Distribution box ( ) Dosing-tank ( )
a Percolation Test Results Performed by---------------------------------------------------
•------------------• Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit..........-......... Depth to ground Water.........................
fir Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground Ovate'r........................
----•---•--....--••-....--••--•-•---•......_._..•-•-•._.....•--......-•---••............:........••--•••••--••-•-.............................................
0 Description of Soil......:---- .........................................................................................................................................................
........................•--•-•-..._......-•-•••••-•-•••••.......... .... -•-•--••••---•••....-•••-•-•--•--•--•-•-••--. ----------------------......•-••-•................ ...---.._....._
x ••-•.......... •••--••--•••-------•••-•`•••••-•-----••--••-----•--•-•---------•••••-•-•---•-......._..•---•- ----- = ---•••• -- ....-•----_••-
- T
U Nature of Repairs or Alterations—Answer when applicable...... lQ.........................../ _�a.__au..................
(� .
, ._.... � ---------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT!.L 5 of the State Sanitary Code— The undersigned further agrees not to'place the system in
operation until a Certificate of Compliance has issued by the boar of hea h.
Signed. ................ •--- ----•-• ._... 3 '7�-!�r. _./
� i Die
Application Approved By... --------- !�-------V ---------------------------- - -----
Date
Application Disapproved for the following reasons:.............................................................................................--.................
.......................................................................................................................................................................................................
Date
PermitNo....... �j ................... Issued.......................................................
Date
Fim
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appl raation for Disposal Works Tonotratr#tun "rrmit
Application is hereby made for a Permit to'Construct ( ) or Repair ( ')-an"Individual Sewage Disposal
System at:
..... _ l'� •! r l r (!C C•-•....................... ' �"=='�` ' .........
...... ........ .. _:.... _.. .._.Y.. .................._
Location•Address or Lot No.
......••.....' ?_l:.�!...... -'--="; . ............................... -Y•/1_ye4!.00.
a T'. Ct Iw-V ) - 7 f�T
� (Address
t-a -....._Owner................. ......_: ...... Y�!_ :�.e ...__............_.._..............._......._.....
W .........................: ....---..
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms...... ...................................
..................... . _....Ex anion Attic
a g— � ________ p ( ) Garbage Grinder ( )
Other—T e of Building No. of,persons Expansion Attic
Showers —
a YP g --------•----------------•-- P ( ) Cafeteria ( )
dOther fixtures --------------- •-----------•------••---•----------._.....---•-•---•--------•-•7•----•...-----•• -...................................................
W Design Flow................. _____________________gallons per person per day. Total daily flow.___ - ____.__.____.___.___._._gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.......I............ Diameter.___A.r :.... Depth below inlet__.__......_... Total leaching area..................sq. ft.
ZOther Distribution box ( l)i Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
0.4
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 •------------------------------------------------------•---•---.....------.......---•=-•-•••---_..............................................................
Descriptionof Soil............................................................................................................................
-_----............................................
W
U Nature of Repairs or Alterations—Answer when applicable. 4�0,o....... _ ................
. "..............
-4z ' =
Agreement:
The undersigned agrees to install the aforedescribed Individual•Sewage Disposal System in accordance with
the provisions of TIT1E 5 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
Application Approved BY . � � __ ............................ -----•...--
Date
Application Disapproved for the following reasons---------------•----------------------------•-----------------------------------•---------------................
.............................................................•-•-----•--•-------•----------••------•------•....---...---•----=--•-------------- _
Date
Permit No....... �C�-..._ .;.------------------- Issued_..................................... .
---- ...---
Date
------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS .—
BOARD OF HEALTH
.......':'::"T:-.._.-±.��!Y....of��..A. .IS,(5 4.0�...............................
Tertif iraa#r of Toutphaanr.e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired O'•'
bY-------------------------------_... --------•-----•--•-•-•--•-•---•.............................•-----•-----•-•--•--------•---
Installer
has been installed in accordance with the provisions of L FY TL' 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.
.---� Cl.
DATE................... • .......................... Inspector.......------. == :,-_,--J
r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
tea' ...... ..................
No. - ?1f� ... FEE..•.2<ft...........
Disposal Work, Tunotrnrtion f rrmit
Permission is hereby granted_.. ,. IDg' == ...fiA
..........
...... 1/1----- ` =^__ a e �--------- --------- .........
i
to Construct ( ) or Repair ( �--)an Individual Sewage Disposal System
at No.. ... t far / _Ir ,.. .� '..........-- E��•_ . r' 1� .t^
Street
p.
as shown on the application for Disposal Works Construction Permit No __!_-_pp.9�_ Dated..........................................
_________________________________ __6_ __..._._....__.__..._................................
Board of Health
DATE. .......... .... . -----.. .` .......................................