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TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. COU • ��F—
SEPTIC TANK CAPACITY 1,�la(J wz 6` -SSS,gwlC,
LEACHING FACILITY:(type) �/ / (size) �X/O
NO. OF BEDROOMS y PRIVATE WELL O BLIC' ATE '
BUILDER OR NEB? /,4�A
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HBALi H
TOWN OF BARNSTA ILE
Appliration for Uiipuaal Works Tututrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair K) an Individual Sewage Disposal
System at:
..... Y... -ate.. .................................................... --`..-...-•--..r----------•------- -------•----..................--.....-•--
Location• ddre / 1 -,,--Or
Lot No. ���JII
... . ........ ................. ........... X-....... ................... ...... .......... .....- ...
Ow ....ner Address
----... .............0.1d ,_...--- ..............................................
Installer Address
Type of Building Size Lot -L06' ...Sq. feet
U Dwelling—No. of Bedrooms................... ............... Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures .----------••••-••-•--•••--••-------•--••••••••---••--.-•.................................•-----.........-•--•--•-•-••----.......-••--.._....------•--
W Design Flow.............................�`.?�___--gallons per person per day. Total daily flow.............�� 6..................
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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................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........................
9 ...............................• -•--... .• . .
ODescription of Soil............................... -0-------------------------------------------------------------------•------------------------------•-------------------
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V ......--•----•----•-----------------------------•--•.........._............------•---.._...._...---.....••--••••--------.._...----.......--••----..._.......•••-•-•--•-•-•---•-•••-••--•-....--••--•--•--
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UNature of Repairs or Alterations—Answer when applicable------,40-4---------/(�GL t`-� �... - ••• -
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 Compliant s en ' s d b he board of health. /
Signed ......... ----- ......... - ....................... --......................--- .9..�......................
Date p
Application Approved BY - ..... .:"./0 - ....
Da e
-
Application Disapproved for the following reasons: -------. ----------------------- -----------------------.-.-............-......-------------------------------
--------------------- ----- ------------- ------ --- ---------------------------------------- --- --------------------------------------------------------------- ---- - -- ------------ .................................
------- ----
Permit No. � --..-..------ .1--- ------------------- Issued ----------............--------...---------. Dare----....... ate.-----
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Disposal Works Tonstrurtiun f rrutif
Application is hereby made for a Permit to Construct ( ) or Repair (K) an Individual Sewage Disposal
System at:
-- - ._-------------------------_......_..__..._.-_.__
-Location-Address or Lot No.
owner
1/��J� �iJ�,�� /__6� L �� /2 Address <.�! �Lr!—i
Installer Address
UType of Building Size Lot_=_a'— -___Sq. feet
�., Dwelling—No. of Bedrooms-----------------
____._��----------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of ersons____________________________ Showers _
W YP g ---------------------------- P ( ) — Cafeteria ( )
04 Other fixtures ------------------------------------------------------------------------------------------------------------------------------------------------------
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Design Flow___________________________ ___gallons per person per day. Total daily flow-------------��- a________________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 ( )
0.4 Percolation Test Results Performed bY------------------------------------•------------------------------------ Date----------------------------------------
Test Pit No. 1________________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________________________
a -----------------------------------------------------------------------------------------------------------------------------------------------------------
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Description of Soil = - --------------•---------------------------------------------------------------------------------------------------------
W
U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -
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--------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable_______ -----------1.6an____niz_ _____ _..____ f�! ..
- c-----------��--------- '��-Srl -----------— c= SS �L?C 'J _
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,,,h2s/ en�Su!d�bt.he- board of health.
H �. _ s �Signed -------- ----=------ = iir�e --------
Application Approved BY ��"�--� 7-�-�--''1----
Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------
Dun'
PermitNo. / 8-k = J j --------------------- Issued -------------------------------------------- ------
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE -
Cex#ifi ate of (gantylian e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ")
by �a✓
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Insrallerr�^
61�
at -----------------------------------------------................................./ 44 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. ...--? .....'6-.-___9------ dated ------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------------------- --------Q------- n- ------------------------- Inspector ------------------------- - ' =-----------------------------------------
a J�
a� THE COMMONWEALTH OF MASSACHUSETTS d f �� 3G
BOARD OF HEALTH
No•_�a.3�: -•._3 TOWN OF BARNSTABLE F> ___ --------
Disposal Vorks Tuns rns#iun famit
Permission is hereby granted. ------------------------------------------------------------------------------------
----
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No------------------------------------------ _Individual
0(J -------`5- --------------� `1cJ-------------------------------
Street �,-N/
as shown on the application for Disposal Works Construction Permit No-J-----------J------- Dated__________________________________________
-`
B-oard-------of H------e-alt-------------------------------------------
h
DATE------------------7..... --- --------------------------
FORM 36508 HOBBS&WARREN,INC..PUBLISHERS