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SUSTAINABLE
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INITIATIVE
Certified Rbor Sourcing
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TOWN OF BAR14STABLE
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I.c�c�ATION SEWAGE
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VILLAGE"ds rcf 2 v i � ASSESSOR'S MAP & LOT
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' IN NAME&hONE NO.
,a SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) t'OL B .ems>'_ ' (size). L /'/o b p
NO. OF BEDROOMS_3,_PRIVATE WELL OR PUBLIC WATER�u
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COZIPLIANC:E ISSUED:
i�
VARIANCE GRANTEI Yes No
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Q
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11
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41
FEz
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Kliipnoal Works Tnnitrnrtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal
System at:
...... .. __�--AY• �vE#2..... C................. .•----•-----------....--•----•---•--------- -----•................••.....
. Location-Address or Lot No.
- ...._..._— .... .....
Owner Address ....... ............. ...
-•---•-
a A 2�.y
Installer Address
Q Type 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
1� Other fixtures ...............................• --
W Design Flow....-.......................................gallons per person per day. Total daily flow...........................-................gallons.
WSeptic Tank—Liquid'capacity.,.'-5"e gallons Length---------------- Width................ Diameter---------------- Depth...........____.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------/------- Diameter......... ...... Depth below inlet....49�........... 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---____--____-_--_._----
fi, 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___ _______7` . .......
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 has been is �d b he board of health.
Signed .!!
!� ..................................................'----.............--....
Application Approved By ---------3 ...... °"' ^w' .3 '40 90
Application Disapproved for the following reasons- ----------------------------------------------------------- -----------------------------..........................................
-------------------------mi-------------------------- ....------------------------------------------------------------------------------------------------------------------------------------------------
---------------------------
�j Ua[e
Pert No ..
. -- ...../.Q....^..1- ---------------------_ Issued ............................................................--- ----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
App iratinn for Disposal Works Tonstrur#inn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (—)man Individual Sewage Disposal
System at:
Location-Address or Lot No.
Owner Address
Installer Address
d Type of Building � Size Lot___________________________S q. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
U
`-4 Other—T e of Building No. of persons............................ Showers l( ) — Cafeteria ( )
Other fixtures --------------------------•-•--------------------------
W Design Flow............................................gallons per person per day. Total daily flow................._._..._.._......_..........gallons.
WSeptic Tank—Liquid*capacity! b vgallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... IAidth.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..........Z....... Diameter..........1------ 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..--....................
G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-------.-_---._..---.
----------------------------•------.........--•--•--•--•--------•--...........---....................--••----------••-------•---.......---•-•-•--••-----•---
0 Description of Soil........................................................................................................................................................................
"4
V ................•---••-----••••••--••-•--.....---•--.........----...................-•----•-------••-•....--•••-•-•---•-•--••--•••--••-•••--•-------•••-•--•-•--•••-•-..........-----•-•-•-•-•-----------
W ;: -------}- --
----
U Nature of Repairs or Alterations—Answer when applicable...U!`�_ .- .7 7 7..�_....... .........
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 has been issued by the board of health.
Signed ........ .. 'a,
7 Date
Application Approved By ..........
-......Q��3�-..---- -: -v. � �--------------------------------------------- ----------.................. 3.--. l3ate.-
Application Disapproved for the following reasons- ..............----------------------------------------------------------------------------------------------------------------
-------- - --------------- -------------------------------------------------------------------------------------------------------- ....................................................... ----------------.......................
Dare
Permit No. ......... .."..1.. ........................ Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tie>r#ifirate of C�ontylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( L�'
by..................-U2 y
------------------------ ---------- ---- --- ---------------------------------------------.............................................................................. ----------------------
Installer ,
at ......c .. �7---...-- yff'� o c v E ---------------Z. ` --..............................................� .��`,�..�--v. .... /cG......------...........--------
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. ......--..r� dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ <_2 ---- ------- Inspectorr. n.:..._....��...ry,......................................... .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
QQ'' TOWN OF BARNSTABLE
No....!.-2.-� �- FEE..
�is�rnsttl arks �nns�rttr�inn .eruti#
,,912
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair (z} an Individual Sewage Disposal System
at No............... ...✓.._./_.�7 )_-% �`/��f� = 'Z G ,-'/ �-Si�"�L �''/�
••-•-•------•-------------------••-•------------•••--...............
Street
as shown on the application for Disposal Works Construction Permit No.. � Dated...........................................
of Health
--•--•-•-------...-•--•--•-•.................................................. l l Board
DATE. �
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS