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OWN OF BARNSTABLE
LOCF:TION ` s SEWAGE # (ga
VILLAGE 6 ST I i ASSESSOR'S MAP & LOT ,P
INSTALLER'S NAME&PHONE
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 5k(4-P6*!U= l— (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER C U iNa�l rvO
PERMITDATE: Bo-Z` COMPLIANCE DATE: l a
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water.Supply Well and Leaching Facility (If any wells exist,
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
fr
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rt'000
ILO CATION SEWAGE '.: PIE RMIT NO.
VILLAGE
I N S T A tLE ; 'S WA-ME A ADDRESS
B U I L D E R OR OWNER
DA T E PERMIT ISSUED l � `7
® DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0[ppYication for Zigool *pztem Con.5tructton Vertu
Application for a Permit to Construct( )Repair(✓Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. 113 -414A)6('9j p5T--rv1 Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel
Installer's Name,Address,and Tell. lNo. / Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3 al gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank LCV0 Type of S.A.S. L`�t CaT Cr'��T LT �oRS
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) nc. St-011 �o'' mac'".
p � S �� r ji
IK-j&c 2S L", `-tt 5-tT,� en— Sr t2S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has Board
Signed A Date le�xi XF7
Application Approved by Date /U—494 7
Application Disapproved for the following reasons
Permit No. 7- b Date Issued
` — �y%o ,-
�l� ZLl � Fee S�, /
fi6 •No. _ V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for Migogar bpgtem Congtruction Permit
`,Application for a Permit to Construct( )Repair(V<Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 'g -4AAJ �jC1d� pgTer�c� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel /Lr(/ h/0
�7 C vP���IVvI
` V
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�eJ 19` V-,-,f—,Ir CK
Type of Building: `
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow '3-3t) gallons per day. Calculated daily flow- --*'> 4`( gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. l S CG✓acr �)r.�ci LT�t'Cr%�
Description of Soil 5 K L
Nature of Repairs or Alterations(Answer when applicable) 1,�<r
70N.-r7.ct—TrayoR5 o„z1L4t 51-cYeQ et- Stf
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Date last inspected: s
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance hasgeg issia Board
Signed Date /d d9—5;7
Application Approved by Date /U—VJ'7
Application Disapproved for the following reasons + _
Permit No. 9 4 `1 Date Issued "
1
---------------------=-----------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERT at tl�e On-si a age Disposal System Constructed( )Repaired-( )Upgraded
Abandoned( )by
at I `*i1i1 to of—r n has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 5�7—G Z Y dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date (� r'� � �) Inspector '7
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigogar *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair(t�pgrade( )Abandon( )
System located at t U A Uv--
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this e it. j
Date: w` Approved by 1ILMC `
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10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
r , hereby certify that the application for disposal works
construction permit signed by me dated 61 — q7 , concerning the
property located at meets all of the
Os-V�V 1``-
following criteria:
L/There are no wetlands located within 100 feet of the proposed leaching facility
V There are no private wells within 150 feet of the proposed septic system
l,, There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
it If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will n2t be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following: /
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) L 7 01 a
B)Observed Groundwater Table Elevation(according to Health Division well map)-a&_o
S GNED: DATE: /O'[�7 g�
LICENSED SEP C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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LOCATION VAl.1 C�t�tI�F1 . ®QId,M_„_. NO. Q�a
VILLAGE OS'rC- -41 L LE DATE
APPLICANT �RI\IQ�IEe D�_ �MEI�,T Co�P. FEE' �3 '
ADDRESS G•g1.lima.-j L1 TELEPHONE N0. 111-3616(Non-refundable
.• HONE NO. 3 • L4
ENGINEE TELEP j>
(A-GE
DATE SCHEDULED' JtJL1� UP 1963 WT
Applicant's signature
I SOIL� .
SUB-DIVISION NAME QEE let 0- 0STt&j.L • -DATE •?��a 63 TIME 9 30
EXPANSION AREA: YES ✓ NO _J O H tot R. . E L L1 S ENGINEER ?
TOWN WATER✓ PRIVATE WELL jot{ty J A C-0 Pa I BOARD OF HEALTH
J I.M...._o P t SCQ L L__ EXCAVATOR
SKETCH: (Street •name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate, wetlands in proximity to test holes)
NOTES:
0
v \
0
! dJ .
PERCOLATION RATE: A4 i rJ /o SJ
TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION:
2 0'- ► 8 L 4, T5 1
2 2
3 3
4 4 -
5 I� _-7 5 F-t
. 6
/� 8
9 GIG t��. ape 9 .� •.�+ a�l
10 10
12 12
13 13
14 14
15 15
16 16
SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS 6
LEACHING TRENCHES
UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS:
r
NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST A LICATION
ORIGINAL: COMPLETED IN P ANR EgIURNED TO BOARD OF HEALTH
COPY! RETAINED BY APPLICANT
No.g - ........ ...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C)q ...............0 F
Appliration for Mipmal Workii Tonstrurtion rnmit
Application is hereby made for a Permit to Construct) or Repair an Individual Sewage Disposal
Sys,em at: �.co.............
C..;- �4.......�)-/-Z.................0..... ... ....
oca ion Address Lot No.
,7 or
..... ........................ja ..(...0...... ...............
................................� . ...... ........... a2�k
ow3er Address
.............................. . .. ...... ..................................................................................................
?
.(. ..
Installer Address
Type of Building Size Lot...11 Sq. feet
U ms Grinder.
Dwelling—No. of Bedrooms .......3-------...................Expansion Attic kV0 GarJ9e
Other—Type of Building ............................ No. of persons........................--.. Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow................5.'.;............_..__..gallons per person per day. Total daily flow............5-2.0...................gallons.
1:4 Septic Tank—Liquid capacit.4J0AU.gallons_- Length................ Width................ Diameter................ Depth................
Disposal Trench—No..............I...... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet................_... Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank
......... Date.......Percolation Test Results Performed by........................or(A
Test Pit No. I Le.SA.minutes per inch Depth of Test Pit . ......... Depth to ground water.........}-"-".-----.
nim it 7......... Depth to ground water..........Test Pit No. minutes per inch Depth of Test P
pG
.............--------- ------------------------
....................... .......... .. .................................
0 Description of Soil.................................. . ....... .........
........................................................ .............�-1 I .................................
U -------*......../--- ... .............
W -7..
1� ........................................................................................................................................................................................................
U 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 TITLE 11LEj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compli nce has been issued by the board- o4+e_alj_h.
Sign .............<� . �, ........
PateApplication Ap rov .............................................................................................. ......
Date
Application Disappr d f the following reasons:...............................................................................................................
.......................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
No........................ Fmc... ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........OF............/314 :�l
........... ...............................
Aplifiration for Uhipoiial Works Tontitrartion rantit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
7 !z�f................0.5 ........................................ ........................................... .. ........
Lora Win•Address or foot No.
.......
.................................. .. ... . .... ... .
.... .........
dress
..................................... ...........
................................. .............. ......... .................................
Installer Address
Type of Building Size Lot../Z...,.e,71....Sq. feet
U .......... ...........................Expansion Attic kl?b
Dwelling— No. of BedroomsGarbage Grinder k(,&
'4
PL4 Other—Type of Building ...... ........ No. of persons......I...................... Showers Cafeteria
P4Other fixtures .........................................................................................I............................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacit,,0__�?-_Q._ga1lons Length............... Width................ Diameter................ Depth...._........__.
Disposal Trench—No. .................... Width............-_...... Total Length_....._............. Total leaching area....................sq. f t.
Seepage Pit No._----_--_.. - __ Diameter.................... Depth below inlet................_._. Total leaching area............--....sq. ft.
Z Other Distribution box Dosing tank
Date.........Percolation Test Results Performed by....................�1!.... .......... .....Pi
Test Pit No. L.0 �.minutes per inch Depth of eest iP�ii .4....... Depth to ground water.._._._........_..
Test Pit No. ...minutes per inch Depth of Test Pit........./...... Depth to ground water........................
.............. . ................... .........................
.......... ............... .................
--------------------------------
0 Description of Soil.................................. 0......46.
U ............................................................................ .. ........................... ............
Z . ........................... ............................................................. ...................... .......................................................................................
U 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 A I'ILE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compli nce has been issued by the board gk+R!qth.
Signed............. . ....... ......... .. ..... .........
Date
Application Ap rove ...... ........................................................................................ ...... ...................
/ Date
Application Disappr the following reasons:..............................................................................................................
......................................................................................................................................................... ...............................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .......................
....... 70k���- .OF.....................g.�. T
Tatifiratr of Tompliatta
THIS IS TO CERTIFY, Tkat the Indlv* I Sewage Disposal System constructed or Repaired
by......................... ..... ..... ... ................ ...........................................................k.....................................
at...............................................Z_ ...... ............... -1.........I
has been inst.--Iled in accordance with t of T TA 4— 5 State Sanita,7,rVy`g-ynes W ----- c * d in the
F" dated ...............................
application for Disposal Works'Construction Permit No.-I;.................fk�......... ....7. ..... ....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE
SYSTEM WILD
YFUNCTION SATISFACTORY.
DATE..... .................................................. Inspector.-- .... ........................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� ....OF.............l
Nof.............. FEE.
.. ...................
FEE.. ..................
Dhipaoal Works TUonotrurtion frrutit
Permission is hereby granted.................... ......04.1....S .....................................
to or Repair an Indivi Z e Construct arg, Disposal System
atNo............................................. ........... .....- -----49L�4-3-------------
Street
as shown on the application for Disposal Works Construction Permit No.. .............Dated.,,,**. ............. ......................
....................... ... ............................................................................
Board of Health
DATE---..2 .......................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
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No.10951�O
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LEGEND CERTIFIED PLOT PLAN
EXISTING .•SPOT ELEVATION 0A0 -s o Mws
EXISTING CONTOUR -- 0
FINISHED SPOT ELEVATION ROBERT .
BRUCE
FINISHED ' CONTOUR . 0 ELDRE r
IN
APPROVED , BOARD OF HEALTH ,1 p3 �..
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,' .. ; r% DATE ?:'per a.:_; .
DATE A;GENT SCALE
LDREDGE.ENGINEERING COLLI!q CLiIrNT _ I CERTIFY THAT THE PROPOSED
EGI3TERE REGISTERED J08 NO. '- BUILDING SHOWN ON TH13 PLAN.
CIVIL LAND w ._ CONFORMS TO THE ZON(NO'LAWS`
ENGINEER UR EY
DROSY1 '�" � . OF ARNSTASLE � . MA
?.12 M A I N. .S TR E ET CH•'8Y
. ... . . ORREO.MA9S. OFNYA N N I S� ATE LAND SURVEY
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10 fT. M�� _ _E�IG1•//NG h/T ARE, .MORE• Ts,l�9:•/ /Z••dFLO.
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C4NCRLrTB M!N_ A/TCN )60E,4V�/ CAST /.PO/N C
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ITOTAL ESa'JJ 'I'E® FLOb4! . 3 3 v 6Ae61,PAVI SOIL Ti�SIr�#t SOIL 7WST¢Fa .2_ SO/L TE.3T
'IYLlMBE,P GF I&ACRlMG OjT.i_ [ lrLL�Y. 34::D
S/OE LEACNIN6 PER o/T g PT. � Y- a4W.E OF SO/L TEST 7 /z& c--3 •
Jo frrpM �7$" �- � z ASS[ILTS Jt/ITNdSSED. dY J.2E• (Jti co G'
t�CX/Nd PAR P!T SQ. A-V
TOTAL I ZACN/ANG a/QEA Z G�r� SQ, or �•C n-> & PF�COLATIO/r ila rE � GAS= ;Ml/'+S/I NCN
?FSERYECEIICNJN6ARE/.� �-�'����,S�O �T
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