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t TOWN OF BARNSTABLE 0P / /q7 L
LOCATION _SEWAGE #TQ!(fa5�23&
VILLAGE 5 ZVAJ C G� L i S ASSES OR'S 1V[f�P& La
INSTALLER'S NAME&PHONE NO. Ja D /
SEPTIC TANK CAPACITY -zoo
LEACHING FACILITY: (type) /l (size) f®D 0
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTFDATE: 3 —I G -- COMPLIANCE DATE: 3 — l"d- — 7
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) J Feet
Edge of Wetland and Leaching Facility(If any wetlands exist x {
within 300 feet o�g aching facility) Feet
Furnished by
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2, . 3 S 5'
3 o r Sd Y I7
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No.... :. ,t.. Fss..........�F�a ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for Di ipw3al Mirlai Tnnitrurtinn ramit
Application is hereby made for a Permit to Construct ( L'�or Repair ( ) an Individual Sewage Disposal
System a� � (.......................................................` .. -. r .�2 G
A -••-..•-o alion- A dress or Lot No.
... . .-. . ___.. •- • --- ----------------•--------_• ....._..----•---------•---••--
O�ner Address
a --• i ��� .----------•----------•----------------------•------------
Installer Address G
�/ ���
� Type of Building Size Lot_________ _________________Sq. feet
Dwelling— No. of Bedrooms---------z----------_-_-_-----.---_-_-----.-.Expansion Attic ( ) Garbage Grinder ( )
Other—Type of BuildiugulL^ 7✓1 No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ _ _< - ---.-----•---..
W Design Flow--------------------------1<_d..........gallot per � per day. Total daily flow--------�.................................gallons.
R: Septic Tank—Liquid capacityl.3�U-gallons Length---------------- Width---------------- Diameter----..-.-.--_--- Depth__- ----_---
W Disposal Trench—No- -------------------- Width.................... Total Length..-_---.•----_.-_--- Total leaching area----------_.........sq. ft.
x
3 Seepage Pit No...................... Diameter..............------ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing nk ( /
Percolation Test Results Performed by. Date......°1..�.��7
--
,`�a Test Pit No. I................minutes per inch Deptl of Test Pit.................... Depth to ground water......41&lk tp .
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
........ ---;
O Description of Soil..... . ._..
W
V ...-••••••-•---•---•...--------••••••••---•••-•••••••--•••-----•---•-•----•----------•-••••••-•-------•••------------------•-----=••--•-•••......-•-----•------•-•--•--•••.._........-•••••-•-••--•-•-•.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
UNature 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 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Com has been issued by t board of health.
Signed ` ......... 7 Q
1�L
Dace
Application.Approved By ..-------�e�w�,.... -�. ------------------------- ------------------------------------------------- ---�i..- Date
q`------
Application Disapproved for the following reasons:
............ .............. .............._ .......... ........_..... ...... ---------------- -------------.....----------------------------------------------- -----------...........................
Permit No. --------�s---------�--L/../------------------------- Issued ------- ..r 1..c2..^.f
Date
f _ r
Ll
-v
No.... >�- �.. Fxs..........�................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE `
Appliratiun for Divi-pw3al Workr, Towitrnrtion Famit
Application is hereby made for a Permit to Construct ( V or Repair ( ) an Individual Sewage Disposal
System at.
vim. ------------------•-------•-----------------....-------------•
�) BLocation- ddress 0 or Lot No
'3.•C � Jam!.
/ ......J/__..:
...........
...._......._.... J Owner Address
---------
'� "'�✓ Installer Address ! / /
UType of Building 41 Size Lot............................Sq. feet
0 4 Dwelling—No. of Bedrooms--------------------------------------------Ez Expansion Attic Garbage Grinder
1.4
P ( ) g ( )
p., Other—Type of Building W��f No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Other fixtures ................ .............. . ..--15A�
-- ----•---------------------------------------
W Design Flow..........................8_0---.------gallons per person per day. Total daily flow.......y�-.--........... ........--gallons.
Gd Septic Tank—Liquid capacity-1�- gallons Length---------------- Width---------------- Diameter....------------ Depth----------------
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 b t l.....V l l,? ............. �l�.' /.. 7
y---- J •--•-----•---••-•••••• Date...•.
Test Pit No. I.................minutes per inch Depth of Test Pit.-.................. Depth to ground water...---.t,/i,/ :.
G Test Pit No. 2----------------minutes per inch Depth of Test Pit----------.--------- Depth to ground water.-.-.----------..-----..
....-•...................................•-•-----------•-------._..............................................................
ODescription of Soil..... .�?...!2P`t..� ---••-•---•--•---------------•-•----•--.......--------•------•-----•-••-•-•----------•-••-•-•---•---............................
x i"
w� ..••• -•--••-------•--------...-•--••---•-------------•••-----------------------------------------•-----------------------------------------••----•••••••-••-----•--•-••-•-••--•--•---••---•----•--••---
VNature 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 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia44GQhas been issued by the/board of health.
ee
Signedt ^'^'l �^•�----- ----------------------------------- ....... Dace
Application.Approved By -------- u- -mil ....a.. f�e-91.5-------
Application Disapproved for the following reasons- ---------------------------------------------------------------------- ---------------------------------------------------
......:........................................................................... ........ ...... _........ . ........ ............. . --. ................. ---------------------------------------
�j Date
Permit No. -- ---.1.�---- --- ------------------------- Issued -----------2..-..�.o.. ?_,_�.------------------
Daze
THE COMMONWEALTH OF MASSACHUSETTS
r
BOARD OF HEALTH
TOWN OF BARNSTABLE
CITer#iftrate of Complinure
THIS IS TO CERTIFY, That th 'ndivid I Sewage Disposal System constructed or Repaired ( )
.......
,�-� Ins all
at ...... ....1(� .....r L✓c L: ...( _. 1 ----------------------------- -----------------------------------------------------......
has been installed in accordance with the provisions of TITLE 5 The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ......
.............. dated .------�_-( .'.T ......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ... .._-..1...' ". --------- Inspector -�.--1 - ---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
NO..-?-q�G.....�.-i-•d••... FEE...... �..�.....
�i��rnsttl_ nrk" "T�.omitr Uan arAit
Permission is hereby granted.... 1 !..52!! V�
to Construct ( or Repair ( ) an Individual Sew�ge Disposal System
at No... .....f l( I ` �� ' l•.t a t:......-----•.....�1-----)44 'D
/ St cet z
as shown on the application for Disposal Works Construction rmi �_1 1- -- Dated---.-- ...D.................-•. C
•
a
Board kIealth
DATE........ ------•---•r /
I FORM 36506 HOBBS 6 WARREN.INC..PUBLISHERS
MAR. 14.1997 8.47AM BAYSIDE BUILDING CO.5087750155 NO.979 P.2i2
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TOWN OF BARNSTABLE
LOCATION C1
SEWAGE # �}�;3
VI S il1iV C �� c
ASSESS
R'S MAP& LOT /
INSTALLER'S NAME&PHONE NO. ///✓✓✓ G
SEPTIC TANK CAPACITY
LEACHING FACILTTy: (type)
NO.OF BEDROOMS (size)
BUILDER OR OWNER l
i
PERMITDATE: = —I G q r" COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �J Feet
Private.Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet o aching facili y) I
Furnished by. /� � Feet
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