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7
LOChTION �j 5EW&6-xE PERMIT UO.
lWSTQLLER•5 1J&ME _ ADDRESS
BUILDER 'S L1 / MF- -� ADDRESS
Dlt TE PERMIT 15SUED
DATE CONAPLI &MCE ISSUED :
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No,............. 0 .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HE L
................OF. ..... .................. .. .:............ ......=.....................
Appliration -fur Disposal Works Toustrurtiuu Vanift
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
Syst at
`_e--4------------------ ..................... fir..3....------------------------------..
Location:Address or Lot N
---------------------- ---------.........--------_..... -?Y� Ar .�����
oW__r__1 Address
Installer Address
d' Type of Building Size Lot_Jvd;. ..7A__8'_Sq. feet
Dwelling 4 No. of Bedrooms--.-_...:.. . .........................Expansion Attic ( ) Garbage Grinder ( )
a ; Other—Type of Building ____________________________ No. of persons_........_....._....__._.__ Showers (e ) — Cafeteria ( )
fQ Other fixtures ----------------•----------•--------•---•-••-----------------•---••----------------•----•-•-•-•--••--------------------------------------------------
W Design Flow....... ... ...........................gallons per person per day. Total daily flow-------3 .Q......._..._._._-_-__..__gallons.
WSeptic T-,iiik!L Liquid capacitvJ �Mallons Length................ Width------.......... Diameter................ Depth...-___-.-----
x Disposal Trench—No- -------------------- Width.................... Total Length-.--___-__._____---- Total leaching area---------------------sq. ft.
Seepage Pit No......;�------------- Diameter__1�_�__--._ Depth below inlet.................... Total leaching< . ----------------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) �� J. '- ��
Percolation Test Results Performed by.......................................................................... Date...------------ ---_-----------------
Test Pit No. 1................minutes per inch Depth of "lest Pit_.-_.-__--__._____-- Depth to ground water._---_---_----.-.-.-.
f� Test Pit No. 2................minutes per inch Depth o Test Pit._____._ ._______. Depth to ground water__.--.-_.-_.-______-----
O .z m y' /,G ----
Description of Soil -^---------- ---•--- ---- G- !�. -� -. ..-_ _. _
U ------------ ---- �
- - ----- ----------------------
W ---q--'-=c
V Nature of Repairs or Alterations—Answer when applicable..------------------- .---_--..____-_.__---._-_-_-_-__------_.-..._--..----_--..-..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 o ealth.
Signe • - ----
DaEe
y
Application Approved By---- •. •.... -- = - -- ------------------
Date
Application Disapproved for the following reasons----------------------------- -----------------•--------•-------------------_-------------------------•----------
Date
i}
PermitNo.............. ...................................... Issued...................... .................................
Date
..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9!F ,H� E L
Cr " OF........ ....r"y...... .. -
Appliratiuu -fur Disposal Workfi Cnuuutrurtinu Vrrut t
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: r
Location:Address or Lot Ngg��
..._ .............. .1 r z r�r 1 : JJS ...
owner _
..
Address
Installer Address
U Type of Building,,� Size Lot-_�1 ... _fi'`Sq. feet
Dwelling�No. of Bedrooms---------------- -_------____•__._---.-_--Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers (l ) — Cafeteria ( )
Otherfixtures ............................................................................... ---------------•-----
W Design Flow.... .. .... ..........................gallons per person per day. Total daily flow-______`0.t)__........_................gallons.
WSeptic Tank Liquid capacitv4;_'_""'gallons Length---__-_-_______ Width................ Diameter_----..-__....__ Depth---.------------
x Disposal Trench—No..................... Width-------------------- Total Length......--------------- Total leaching area--------------------sq. ft.
Seepage Pit No....../------------ Diameter.`._"''_n1.----- Depth below inlet_______________ ___ Total leaching< a------.:__._..._-sq. ft.
Z Other Distribution box ( ) Dosing tank .2 J- 7 G
aPercolation Test Results Performed bY-------------------------------------------- ............................. Date---------------------------------------
Test Pit No. 1______•-.._____-minutes per inch Depth of "Kest Pit.................... Depth to ground water..------__-_-_.__.
/f=/, Test Pit No. 2................minutes per inch Depth of Test Pit.-----_ ...._.__. Depth to ground water__.._..____.._.___._.__.
W _________________________�__-_._ _C( - _.____ ____ ......._._...`. ......._.__
O -----------------------
Description of Soil-------w- --- ---•--... . --•-----.. --------------- -- --=--�_�___`-'r•+'_- ...._ � -
x _
V Nature of Repairs or Alterations—Answer when applicable.____________________________________________----
_--------------------------------------------
_.
-----------------•--•--------•-----------------------------------------------............................----------•----------•--------------•------------------------------------•---- --------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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,�ealth. B
Sign :- ....... --------------
/�(r.t'J.... .
Date
Application Approved B
Date
Application Disapproved for the following reasons:-.-..--- ..................--....---.._._.........----•----._...........-------•----•__..._...___._._.____...._
.•-• --••-------------•----------------•--------------•----------•---•-•--•-••---•---•------•-
--------------------------------------------------------------------------------
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL
, .................OF...... . ......
�74 ... .......................
w,rrtifiratr of ferrutpliaurr
IS IS TO T That the Individual Sewage Disposal System constructed ( or Repaired ( )
by :. -----------
� Installe
l � `�1-� ' �----- - --- --
has been installed in accordance with the provisions of : cI XI o./f Tl State Sanitary.LCpdefas described in the
application for Disposal Works Construction Permit No-----------K_ %______________•_- dated_.--( -___�t_�-._'_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL-k-FUNCTION SATISFACTORY. U
DATE `�g� � -----------
Inspector. = ^'�
G,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
t
:.,....... .......OF....... ........................... /
No. FEE/---�--••------•-
i� �a l urk uu -urtiuu
Prrmit
Permission s eby granted.------ . ............... .•---------...----------•----•------....-•---...---•---._._..
to Constr t ) or Repairg an/Individual ge Disposal Syste
atNo :. / � ,✓4. - ---•-------1�!1!(./�.e ------- -- ----------_-: ---------- ---------.........................
Street _
as shown on the application for Disposal Works Construction t * -,,- --a___- Dated__ . ........12`_46_ ,
.................................
DATE...... ��-s- -- - ----•--- -----------------------•--------•- Board o f Healt `
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
is
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APO
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w CERTIFIED PLOT PLAN
LOCATION �'aT1n1S MASS.
SCALE �=N i . . . . DATE .��`I4I76 .
PLAN REFERENCE . . ZOt W/ .aS. shOtVn
A Ma0t-AAS E. KEG LEY CO. on.J.pnd. .Gourt
LAND SURVEYORS
346 �LONG POND DRIVE 1
SOU"Iti YARMOtJTH, MASS.
02664
I CERTIFY THAT THE FOUIDA` TON. SHOWN
ON THIS PLAN IS LOCATED ON THE GROUND'
AS SHOWN HEREON AND THAT IT CONFORMS TO
Builder William Aa JOJohnsonT THE ZONING LAWS OF THE TOWN OF
i �ARNSAT.k�. . . . . . . . . N CONSTRUCTED
245 barker Road �J
West Barnstable} Mass 02668 DATE .
PETITIONER :
REG. LAND S R EYOR