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TOWN OF BARNSTABLE
LOCAi'iON � _ SEWAGE.# �O ;5
�
VILLAGE (e'0 ria(T _ ASSESSOR'S MAP & LOT
INSTALLER'S NAME& PHONE NO. L BUJ =fe jq�3
Cow r� Str (��C-,r b'AQn�S�► z�
SEPTIC TANK CAPACITY_
LEACHING FACILITY:(type)�j 'T (size) 6)0 C)
NO.OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 4D o L ktS
DATE.PERMIT ISSUED:
DATE COLIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
UFG U=ZP;P-
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=021003006&seq=1 8/25/2015
_ l TOWN OF BARNSTABLS Doll 4�v3w00
LOCA`i'ION _ SEWAGE # A
VILLAGE_ aorarrC?1 ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. v (p2,—lpF�gr�-
SisPTIC TANK CAPACITY ✓� �A�i- k/C�-r6.0eas(Y
LEACHING FACILITY:(type)__ (size)` 0 0
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER_- % L� &4crcl �
DATE PERMIT ISSUED:_z�i
DATE COMPLIANCE ISSUED .elm ^ ��
VARIANCE GRANTED: Yes No
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No..... ....c�n� F�a .. _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA TH
OF.......... .. ... ..._.........._......
App iration for UWposal Works Tonstruitiun Vamit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
Syst7 a a
... &Li_-_
..
................. t.... 1er.......... � � L resl�`�
Installer ���***iii���Address ,['�
Type of Building "Z Size Lot _--9...............Sq. feet
U Dwelling—No. of Bedrooms...._._.�,f Expansion Attic ( ) Garbage Grinder�+ ------_-----_--•--- —
`� Other—T e of BuildingNo. of persons............................ Showers Cafeteria
Q' 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..................... Vidth.................... 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--___-_______-__---..__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------------------------------------------------
-...........................................................................................
0 Description of Soil........................................................................................................................................................................
x
U
W
x ----••-•----------------------------•----------------•----•----•••-------••-----------......-••-•-•-----•-•--•-----•-------------------•----•---------------------------------------•--•-•••••-•••......
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
................................................ --•---•. • •---.-------- --tode
-------------------------------------------------------------•------•--Agreement:
The undersigned a inst t e aford Individual Sewage Disposal System in accordance with
the provisions of iITI.L 5 of the State Sanitary The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue by a
Signed----...... --•----•-•....................................•-•...------------_....
Application Approved By.._.. ----�% ........... .... ice' ._. ��_
Application Disapproved for the following reasons-------------------------••--- ...............................................................
0.........
_.._
.............................................................---.....................-...................................................................................................................
Date
Permit No.....0�`* v
• --.. Issued..........7 ----- 71 .,�......
--
Date
No......................... F:zs..................._.....
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF �EATT
.................;?� ..:. .:.:.. ......0F.......... 'x- ..... .._ .........--••-----•-
Appliration for Disposal Works Tonstrnr#iun firrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disp sal
System at
................_....._
ir"It
A J or Lot N
..............ie
.............. ..... ...... Z.�0 ..
FCAfQYvner { Q Address ,
Installer Address
dType of Building Size Lot. .............Sq. feet
U Dwelling—No. of Bedrooms._... .....Expansion Attic ( ) Garbage Grinder
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -------------------------------• •• -
Design Flow............................................gallons per person per day. Total daily flow...................0..._.............._.....gallons..
W
WSeptic Tank—Liquid capacity.6�.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........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' --•-----...--•--------------•-••-•--••••--•••-••--•--•••...........•-------------------••-•--------•.........................................................
0 Description of Soil........................................................................................................................................................................
W
V •-•-•---•••••••---••--•-•-•••-•••-•-•-•-----•-•-•------•----•••------••--•-----•---•......--•••-•-••------------•-••--•••••-----•---•••------••••---•----•-•----•-•-•......................................................
W --•---•---••----------••-•-•-------------••-----•••-•---------•----••-•-----•---------•---••----•••----•-••--------------------•---•••••-----••-•-•-....•--••-•--•••------•.............-•----...._.....
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement
The undersigned a o in a th aforede ribed Individual Sewage Disposal System in accordance with
the provisions of TITA LZ 5 of the State Sanitary ode—The undersi ned furtl: r agrees not to place the system in
operation until a Certificate of Compliance has been issue by and al
-
Signed ------------_---
ate
ApplicationApproved By.........................................---------•----•-•------•••---------------•----------- ------------------------------......----
Date
Application Disapproved for the following reasons:-------•------------------------------------•-------•---------•-------------.•...-----•-•••.....•-•---..........
---------------------•--........----------•-•-----....---.....-----------.........------......--.......----------------------------------------------------- ...........................................
Date
PermitNo.---•--•----••-••------••---........-•••••-•-•-•••....... Issued---------------•-----•••---•••••....` ----------••-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
•-6.k
BOARD OF HEALTH
Gf ...............OF... ................................
�r�i�irtt#.e laf f�unt�li�nr�e
THIS IS TO CER I Y, That t Individual Sewage Disposal System constructed ( or Repaired ( )
i
_ - Install
at.--- --V mil _.. `/ 11;0of.-:.`fin- '�� A...... ..<`C.... �... f!
has been installed in accordance with the provisions of T I, �d.E 5 of The State Sanitar Code as described�=I' .the
application for Disposal Works Construction Permit No._ `.. _Vt, .__...... dated-.7--- 1 ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEE�AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ Inspector....:_.
------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C� w .............OF..../r�. 1.,....f :..........
No/... e�'� FEZ ..........
Permissio is ereby granted----•------ _....
to Construct I or Repair ( ) an I div'duaI Sewage S�,ossal Systems
at No.._.�` ::.. __ ll!/f! _4>"'? P-- �' , ;....................
Street
as shown on the application for Disposal Works Construction Permit N�.~ ..... Dated..........................................
............................... ...... .................................................
^ O
DATE--------------------- --.. .........-----...__..................... Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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