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THE COMMONWEALTH OF MASSACHUSETTS Oe00
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diopnoa1 Workii Cnnnitrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 4 T,
r V
lion Address 71i o t No ���-fI`�•�
......r_....._.... ....... .................................... ......................... . ........... .. .............. .....................
Address
------------------- ------------------------------------------------------------•--------_.... ...................................... ---- -- -- .4
Installer Address
VType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.......... .............._..........Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
P4 Other fixtures _----•-------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter................ Depth................
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. I................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-------:................
P4 ----•-------•--•----------------------•-------•-••------....---.....-------------------.....---.._..........._.....--•---------•--------------...------------
0 Description of Soil-------------------------------------------------------------------------------------------------------------------•---•------•-----------------------•----------------
x
W ----------------------------------------------------------------•-----------•----------...._------•-----------
/- ----------------------------------
x Nature of Re airs or Alterations—Answer when applicable_. /' _ �-=_ fd•�__ _.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmenta�een
de—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance issued b the board of health.
Signed --- ....----... . : . .................
Dace
Application Approved BY - -- -- ----- -- -- ------------ --- --- -- - - - ----- --- - - --- ----------------....-.-.
-------------------------------------
Dare
Application Disapproved for the following rea s: ---------------- ..................................-------------------------- -------------------------------....................
- / . ..
7
-----------
- re
Permit No. ................
--.�.-- - ............. Issued ...---F---�9-.. - e
No. .t� ............................_
THE COMMONWEALTH OF MASSACHUSETTSC�.oC�
BOARD OF HEALTH _
! TOWN OF BARNSTABLE ,,
Appliration for Disposal Works Tonstrurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
............ ._.... ............................................... .................. ---------------
-oeation-Address .�o� or Lot No
;-�
Owner— Address
W ���':sue.-j_.!GvS:---�'"��-�-_. .�-t,' - c�-..� �`tr1V� z�, .• 1--=- ��,�-�'I�_ -
Installer Address
d Type of Building Size Lot................------------Sq. feet
U Dwelling—No. of Bedrooms...................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
P. 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. I................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-___•._____-_-__--_____.
a ------------------•---••......--------------------------------------•--......•......----------------.........................................................
0 Description of Soil...............................................................................--------------------------------------------------------------------------••----•-••-
x
x ----•----•------------------••---•-•-----•------------•---•---•••....................................................... ..................................... -•--- -------
U \Nature of Repairs or Alterations—Answer when applicable_._ __ 0--- ----------- 5-- -. f .
greement:
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 hdbeen issued by the board of health.
i �
Signed= _ -- ----------- = -- ---- ---------------"--- '......................... Dace
Q-
Application Approved BY ... - --
Date
Application Disapproved for the followingtreas .s: t
/ f....... ......
Date
Permit No. ----- ................... .. Issued
.................------------
Date f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifira#e af Contylianre
THIS IS TO CERTIFY, That the Individual S wage Disposal System constructed ( ) or Repaired ( )
by-- --. 'c����! . _.v:..........��. ����- ��� {� �'.........-----'.. . .. .. .. .... ................................. ..............................------------
Install r
�r',S_ l/yj ��A�r��s s 4
at p -------------------------------------------------------------------------------------------------- ------ ------------------
has been installed in accordance with the provisions of TITLE of The St e ronmental Cj a cr'b in M `
the application for Disposal Works Construction Permit No. V-914STRUED
.......... . .. .. .... dated C./. ..-. ------ .. .....
T A A •RANTEE HAT THE
THE ISSUANCE OF THIS CERTIFICATE SHALL NOS GUI
SYSTEM WILr'L
U CTIOKSATISFACTORY.
DATE---------q ' -------------------------------------------- ------------------- Inspector -... ---...----....--------......-------------------------- ------........-- . . ....
THE COMMONWEALTH OF MASSACHUSETTS.
BOARD OF HEALTH
TOWN OF BARNSTABLE Ob
No...�..,,.._........ FsE.....
....................
Disposal Works Tonstrurtionr rutit
Permission is hereby granted....__..._� �. ��� ��
to Construct�i�) or R p��( j�a��nVividual ewJage Di po's System f
6er
--- -
t / C/�
as shown on the application or Disposal Works Construction ---- --
Street . tech..................... ...!...........
Board of Health,
DATE............ _ ,7.....•... -
FORM 36508 HOBBS A WARREN,INC..PUBLISHERS -