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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ��
Yes
dI a/ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Digonl *pftem Cow5truction Vermit
Application for a Permit to Construct(K)Repair( )Upgrade( )Abandon( ) ❑Complete System 0 Individual Components
Location Address or Lot No. L I B - / Owner's Name,Address and Tel.No. -
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
✓L Z 2_
Type of Building:
Dwelling No.of Bedrooms _ Lot Size 005 sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures QQ
Design Flow `",'o gallons per day. Calculated daily flow 4 Af ' gallons.
Plan Date 95 Number of sheets ( Revision Date �•
Title
Size of Septic Tank 5-0O Cot A Z - Type of S.A.S. L-9 Aie-tA 'r-aC&kr-b1'E-S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 been issued ty this Board of Health.
Signed 0�AC-1- Date 711dqk,
Application Approved by Date 60
Application Disapproved for the following reasons
Permit No. — 36 Date Issued ��
TOWN OF BARNSTABLE
LOCATION LO V- SEWAGE #
VII.LAGE �� �— ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. IV�
SEPTIC TANK CAPACITY d
LEACHING FACILITY: (type) T re'l0 L (size) X3'7
NO. OF BEDROOMS
BUILDE R OAR r�S
PERMITDATE: t COMPLIANCE DATE: ? l3 9
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 fe of eaching facility) Feet
Furnished by
ti
,k \ p 16
16r
No. .,. . Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION —TOWN OF.BARNSTABLE., MASSACHUSETTS S/�A('?Ok,ai(a4-&
ZIPPrtcatton fir Mtgooar &pgtetn Congtructton Vermtt
Application for a Permit to Construct QC)Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. n
Assessor's Map/Parcel 8
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size 21 eO5sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `( gallons per day. Calculated daily flow I gallons._
Plan Date Z�1 Number of sheets ( Revision Date 1/ JA
Title
Size of Septic Tank 1500 6f Ate' Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) /
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 Cod and not to place the system in operation until a Certifi-
cate of Compliance has been issued k4this Board of He®alth.�'
Signed r�!Q� Y� , , Date 7 t 4 S-
Application Approved by C Date 60 /t-14,jorl�
Application Disapproved for the following reasons
Permit No. Date Issued
------- ——————————————--- ---`= — v -------
= THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certtftcate of Compliance f'
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( ) Upgraded( )
Abandoned( )by r
;if
at Zo i�//i GLv+ tv 44 Ak� / -44i 11f has been constructed in accordance
with the provisions of Title 5 and'the for Disposal System Construction Permit No. 3(<! dated
Installer Designer
The issuance of this pe t shall not be construed as a guarantee that the system Will"function as designed.
Date �J_ 9 Inspector
(�/ - —------------------------- —Fee
No: /
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE., MASSACHUSETTS
i r
r
utopont Abpgtem Conotructton Vernttt
Ile
Permission is hereby granted to Construct(K Repair( )Upgrade( )Abandon( )
System located at ..�o'7t �T i��i Gv+�l �✓G"'� , ��C�i f s / l�/,�/f
P
;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 comMeted wi tt t. ie- years of the date of s p� er`nut.
/ Date: �� Approved by h l / /! t
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