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TOWN OF BARNSTABLE
LOCATION ` 5 T- SEWAGE
VILLAGE p 'i, 1 7' ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY l oO D Cr3-l O 4,
LEACHING FACILITY:(tVpe) / (s1C7 D Lfae, f l (sue)
NO. OF BEDROOMS- TE
PRIVATE WELL OR PUBLIC
BUILDER OR OWNER
DATE PERMIT"ISSUEDe "
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED:` Yes No ��
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair (4.) an Individual Sewage Disposal
System at:
or Ljot
Owner Add,ess
Installer Addre
Z Other Distribution box ( ) Dosing tank ( )
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL 11i LE 5 of the State Sanitary Code—The undersigned furtherugreesuottoplacede system in
| operation nodl a Certificate of Compliance has bcco issued by tbcbo dof6od66
� '
- a*Mueu .......... ' __
Date
Application Approved 8y----- -_'^_�����
d Date
Application Disapproved for the following reasons:................................................................................................................
.......................................................................................................................................................................................................
w,
'No... :.. Fi$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............ ......--........---......O F..... .........................:........--------------------------------------...---•---•
Appliration for Dispaii al Works Tomitrnrtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.....---•................._.......................--•--........-•--••......--------••-•-•----•... -.......-----------------•-•-••---••--------------••-----•-•------------------•---------•---------
Location-Address or Lot No.
......................_.......................................................................... ..................•-----••--••------•••---.........•---••...•-----....---..._.........--••--------
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
V 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.
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.................... 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........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•----------------------•--------•--................................------------------------------•--.........................................................
0 Description of Soil......................................................................................................................................................................
x
V •-••----....---•••••--••-•-------•-------••--•------•-••--------------•-•••---••••--•-••----...---•••---••••----•--------•-----•--••------•--•-------------------------••--••.................----•-----
----------------------------- ----------------------------------------•----......-----......._..---•-------------------------------------------------------------------------------------------•---•----
UNature of Repairs or Alterations—Answer when applicable....................................:............:........ ....:......:.............:.........
1 i I
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI'L11 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........... ------ = - ..................................•-- ........... `G r���••
Date
Application Disapproved for the following reasons:................................................................................................................
..............................................I.......................................................................................................................... ...............................
Date
Permit No.. .
......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F.....................................................................................
Trrtifgrate of Tome hart
THIS I T CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
byl- -------•- ��ti - --------------------------- ---------...................----------•---------------............. .......
Ialler
---•------•-----7 •-------� ry----•-- `- ..----
at
has been installed in accordance with the provisions of j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.____-�_=__-VY 7...... 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
C ...........................................OF...................... .......:....................................................
No. i�--�4`l Z-• . FEE.........................
Ehoposa1 Vorkn �� tr rt�la�t rr�t�t
Permission is hereby granted..........
t-J-- =y=�c�'Gr .........................
to Construct ) or Repair ( ) an Individual Sew e Disp sal System
atNo.............. Z�'....... .z!'c. ........S..�.. r t..._ --• •�--•--..L............ ...........•-----....._.__.......------....
Street
as shown on the application for Disposal Works Construction Permit No� �'f7Dated•.........................................
.................................... =--t ...........................................................
C
DATE..................
..............................7......... Board of Health
----�------`--�
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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