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LO,CAT10 SEWAGE PERMIT NO..
g6 ( k Pam,
VILLAGE
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INSTA LLER'S NAME & ADDRESS
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B UI,LDE R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED � _
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HUSET
THE ®P'yRWEAOI� FHEAc TH TS
----------OF... t_ j
Appltra tau -fear Bhip sal Works Towitrurtion Vane t
Application is hereby made for a Permit to Construct r it pp y t ct ( ) o Repair ( ) an Individual Sewage Dtspos
S semat:
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�o s orIof..N...o.....
d 6_1 _0 1i 6
....................... -- ............................................................. ......................... . -..........--•--•--------•---••••••...........---••-...........
�j Owner Address
. ...................... --•--......----------•--•---------------- •----...--••-•-----••-----•------....-......----------.....----•--------------.....------•--•-•---
---------
Installer Address
Q Type of Building Size Lot-_-------------------------Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a _ Other—Type of Building ............................ No. of persons....--...................... Showers ( ) — Cafeteria ( )
Otherfixtures ......................................................------..................---•------
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.......................... ............
a
Test Pit No. 1................minutes,per inch Depth of Test Pit.....-------.------- Depth to ground water....-----.._------_--
f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._..............---.
P4 ----- -------------------------------------------------••••-----•-•-•.........••...........................................................................
0 "Description of Soil-----T-•-�/e--G�. a,
x
-------------------------------------------------------------------------------------------------------------------------------------- >
U Nature of Repairs or Alterations—Answer when applicable...��z'O....... -�' v!J��'
U cv.....
- -------------------------
------------------------------------------------------------------------------------------------------------------------------------- ••-------------------------------
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 be issued the board of health..
` s
Sign /� /7•--•--- ---
Date
Application Approved By........ --- - --- ------- -- - �-���-C�d''- -----�•-------------- ........................ ...............
Date
Application Disapproved for the following reasons:---•--.................. ---.....--•.........................••••-•-....•---------•••........-------•••-•-----
....... ••-••----•------••---•----------------••••••.................-
Date
PermitNo.......................................---•-•-•---•-----• Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARQ OF HEA TH
x !y+�. "' d',• 0
... ._......OF....... --. ..............`-�... ... .................
AvAiratinn -fear Ravasat Workii Cnnn,itrnrtion Prrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual.,Sewage Disposal
S st n at:
-----------•-•----------------
�An �lress or Lot No.
..........
� Owner �� t�` � Address
.......................................... •-•--________._
Installer Address •
d TYP __ _ _ Sq. feet
e of Building Size Lot____________________ _____
U Dwelling=No. of Bedroom_s............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ---------------------------- No. of persons...................__-___- ( ) ( )
-- Showers — Cafeteria
dOther`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
aPercolation Test Results Performed by----- - ----------------------•-------•---•-••••--•-.____•-------••-•---- Date----------------------------------
Test Pit No. L______,__:•__-_minutes per inch Depth of "Pest Pit____________________ Depth,to ground water-..___-__-__--__-_-"--.
(s, Test Pit No. 2................minutes per inch Depth of Test Pit"________.__________ Depth to ground water__"__-______________"--
rx -- ••-•--••••----------------------••--•---•_______.__.______._..........................................................
O Description of Soil_ -'���-----�-----! J _ ----------------------
d
U Nature of Repairs or Alterations—Answer when applicable---Z�� -___.._ _ ------------
-----------------------------------------------------------------------------------------------------
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 bgpa issued the board of health.
,,�►� '7 7
SignG c j' -••------------------------------•--- Date
Application Approved BY------ - _----------7.- ----�.-------•----•--- Date
Application Disapproved for the following reasons__________--------------- ____________________________________________•__._.._..__.__.___-________._.___._______
..................................-------------------------------------------------
Date
PermitNo---------------------------.........:-------=............ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
` BOARD OF HEALTH
. ... OF.....�..�. - .....-.-..."-.-...-..-
Trxtifirate of 011pnmpfianre
b -HISYIS TO/C ��, That the Individual Sewage Disposal System constructed ( ) or Repaired
G„ �(P y Inst111er /
has been installed in accordance with the provisions ofArti of The State Sanitary C de as described in the
application for Disposal Works'Construction Permit No.`' 7�___---2_�:tt-____ dated -- -"'_ .:-. ` __________________
THE ISSUANCE,',,OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT-THE
SYSTEM WILL UN TION SATISFACTORY. :•.
DATE / /`� 77•••:•- Inspector•- ...................................... .
f f y
THE COMMONWEALTH OF MASSACHUSETTS
BA R- HEALTH F
' { OF ....-................................... ---...".-.-••----........ t c 7
O-•-- •--------•• FEE........................
u,
Pin0atiO Park.4 TTonitrurtinn tiermit
Permission ts_.he`reby granted_,_____°- _-_ _______ _�____
to C3 "uct (t'` ) o�epair ( ) an Indi d�,tal Sewage isposal System
at No. C r ....
Street
as shown on the application for Disposal Works Construction r it No. _ _� __..-____ ated----- 1;77
ar o Health
DATE---- --------- --------------------------------------------
��,w.- /•e.���..�i '/
FORM 1255 Hoees &-WARREN. INC`.. PUBLISHERS
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TOWN OF. BARNSTABLE A A G
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
A ^E MAP N0. PARCEL NO. -
So SSORS �� �c
ADDRESS; VILLAGE* 05 4PV)LLg
CONTACT PERSON At b WeV Z) PHONE NUMBER
LOCATION OF TANKS: . CAPACITY: TYPE--OF- FUEL AGE: TYPE: LEAK
OR CHEMICAL. DETECTION
SYS ��It
DATE OF PURCHASE OF EACH: 1. 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT: -
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD.
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