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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirttfilan for Diipnsal Workii Tomi rurtinn runfit
Application is hereby made for a Permit to Construct ( ) or Repair ( D an Individual Sewage Disposal
System at:
-QJA t N o..7 d/ /,SCA.
... . A ............................ ..........................................................
-----
ddre � M-..Y...V� C U T . ..... ....... / ._'S
P=
o
:....
Installer Address
Type of Building Size Lot ..................Sq. feet
U Dwelling—No. of Bedrooms..............-3........__ .___.Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures •----------------••---------•--•-••---• .
w Design Flow...................... ............gallons per person per day.. Total daily flow____.__..._ a...................gallons.
WSeptic Tank—Liquid capacity/M-O.gallons Length................ Width................ Diameter-_-_._-•.___•-_- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No---------G�.._... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) '
Percolation Test Results Performed by.......................................................................... Date........................................
t_l
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
1-4
Ist Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-______-__--. ____-
a' ----------------------------------------•----------•-------•---....---------••-......•-••-••----•-•--•-.....----..._...........-----------•----....---••-•--
O Description of Soil................... S `o ` ........../SS
x
w
----------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature of pairs or Alterations—Answer when applicable l Ud ---Ot/£� COIU,..------•.
.......... -------•--------•-•-•-•--------------•-------------------------------------------.......
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�a be n issued y t board of health.
�y
Signed �� f............ ............
j..........
Date
Application Approved By --------------- ------.......-------------------------------------- .. ...�
Application Disapproved for the following reasons- -- ------- ----------------------------------------------------------------------------------------------..........
------- ----------
-------------------- -
Date
PermitNo. -----------?/....... 3----------_-----------_ Issued .............................................................------
Date
No._;.. ... ... a .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Ui"osal Works Tnnitrnrtion Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
.........../`� ....../..SO....I..........?l ..
.........Location
-••-••Location-Address or Lot No.
sp
Owner.OAJ= 7 Address .,l
------------------------------------- •-----•------•---•••••••----- ••------•-----.......... 1�........ `�. - .
Installer Address '
U Type of Building Size Lot :A�QQ......Sq. feet
Dwelling—No. of Bedrooms................-:��..._...._.............Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ......... No. of persons................•...•....... Showers — Cafeteria
QI Other fixtures ---------------------------------•----- -
w Design Flow.•................. -? .........gallons per person per day. Total daily flow---........ r...................gallons.
WSeptic Tank—Liquid capacity/446..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........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-.----.-..---.----.....-
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--....................
a -••---••--•-••••••------•---•--••-••---••-•-•---------•-----------------------------------------•---.........................................................
O Description of Soil..... -- _.....CCr!J-r .SCJSd��� -_- ---- Z.-r.:54A4..
x
x ----------------------•---•---------------•---••---............-----------•-•------•-----•-•----••--•-•--••.......-•---•----•---------•-----••-•------•-•--•----................-•-•••--••---•----...
U Nature of Pyepairs or Alterations—Answer when applicable.----- -......�12��Yr�, �JF fL�� ........
/ . ....••-• -------------•--•-•------•--------•-••---......-----------------------------------...----------•--••-•-•---•-•----------•......-•--•--••------....•---
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 ;�?- Date
Application Approved B �.. - ----....--'----'--- .................
PP PP Y - _ Date..
Application Disapproved for the fo lowing reasons: ...................................................................'............................ --_---_----------_-------- -
-------------- -- ---------------------------------------------- -------...................... ............................................................_................................. ....................................
Dte
Permit No. �l Id .
...-...-.... .----.../ ................................ .......
Issued Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(ferttftrate of (fomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by...................................................... ......... ................................................................. ...............
Installer
at - -...........�/�1 �4/�SUnI 1�(J.-... � t-------2r------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental (;ode as described in
the application for Disposal Works Construction Permit No. .............o?/....... .3......... dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... ....................... '...... ............. ... - Inspector- .......
.... 12'<...
' r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C�'f TOWN OF BARNSTABLE
No............�.�,. FEE.�-lJ............
Disposal Works Tonstrnrtion "prrmit
Permission is hereby granted................e_?d -�T�---1� .............�Z4 ....................................................
to Construct ( ) or Repair_,K) an Individual Sewage Disposal System
atNo..................................... 1 1. .1 ............. .V/5,1.................
Street c�
as shown on the application for Disposal Works Construction Permit l�jo,.%l ��... Dated..........................................
........................... ....------.................................................
Board of Health
DATE - ).... ...:;
FORM 36506 HOBBS&WARREN.INC..PUBLISHERS