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EERMTT DATE
I:IANCE DATE
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TOWN OF B�JARNSTTABLE Ot
LOCATION 7,(C� �� h A/I. SEWAGE #70,04 Ali
.
VILLAGE t I , l5,Vrryt ASSESSOR'S MAP & LOT'
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY l,5_00
LEACHING FACILITY: (type) (size) *��®D QR
i
NO.OF BEDROOMS
BUILDER OR OWNER k (14j ct lura 4%wL I
PERMITDATE: �/� ? °�® Cf COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility / Feet
Private Water Supply Welland Leaching Facility (If any wells exist !
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Fac' 'ty(If any wetlands exist f
within 300 feet of leaching fa ' ty) / Feet
Furnished by i
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,� ZIP.�
TOWN'O)=B,ARNSTABLE'.
LOCATION 2{Q����}���-.;�L�, c�►..SEWAGE#70Dt1.
' VIILAGEE�5l�'� ASSESSOR'S.MAP &LOT
INSTALLER'S NAME&PHONE�O .G s�}tleC�G(�l�
:SEPTIC IG TAN -CAPACITY , ..
I�ACHINEr�ACI�Ff'3� '(type) 'L�r `{5��� r'arQ
NO.OF BEDROOMS - -
BUILDER OR OWNER �'ti�='� ��U�+ � t
PERMITDATE— COMPLIANCE DAM,
Separation Distance Between the
Maxim Cren �ater_TabteatumAdtis ]. tt04 4, cWngFa ty: /'� Feet
Private Water Supply We1�4an� cbiiig Facility any +e exist
t�ti site Qr witliiri 200 feed.of leaettiu�facile �,�; .-�.t�`�. � ..�� � '�-
�.�,• �� �it Y��'.��'��� rt {�- „7.� � -#' erx' �Z�'.9�.ha• �'{ , 'a t'P''-•n-+u �..,�.. 1
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No. ;Info Fee 1.0-ID
c�,.,.1 THE COMMONWEALTH OF MASSACH US ETTS Enter
` I �� �d in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplication for Migool *p$tem Cott$truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Lo n Address or Lot �(S f� wner's Name,Address and Tel.No. /
Assdessor's Map/Pazcel � -'b/ Z) � ` L., 4
Installer's Name,Address,and Tel.No.OF Designer's Name,Address and Tel.No.
7 G7
Type of Building:
Dwelling No.of Bedrooms _ Lot Size— sy.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /XU gallons per day. Calculated daily flow 776 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 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 Code and not to place the system in operation until a rtifi-
cate of Compliance has been issued by this Board o Health.
Signed Date
Application Approved by Date
Application Disapproved for the ollow%ng reasons
Permit No. lagp 7-U Date Issued
No.
Fee 'cf3 U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
ZIpprication for Migooal *pgtem Con6truction Permit
Application for Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
41
Lo on ddre�;Lot Z (S f( �///7J i Owner's Name,Address and Tel.No.
CC 1 / ��{�r*%'� � ��L °
Asse1r'� /Farce
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. cv
Type of Building:
Dwelling No.of Bedrooms Lot Size Z sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures f,
Design Flow 3 x gallons per day. Calculated daily flow 70 gallons.
" Plan Date Number of sheets :"Revision Date
Title
Size of Septic Tank f Type of S.A.S. U c
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 ertifl-
cate of Compliance has been issued by this Board.V Health. ell
Signed Date UG
Application Approved by Date
Application Disapproved for the following reasons
Permit No. v0 — '�. tt� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Complianue
THIS IS TO C3RTIFY, that the O -site See age Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )b G f"�` /� - Cv C C, ! O'l
at � U (' has been constructed in accordance
with the provisiops of Title 5 and the for Pisposo Systeryi Construction Permit No. dated
Installer /���/ �// y , Designer Y .,'UT.,
The issuance of this permit shalt no b construed as a guarantee that the s (tem �11 tinctionTas ,ekigne,0J��� (Ij,
Date �. Inspector '���f�'���1
J
---------------------------------------
No. r1i 000'� j� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
30igpoo"pelem Construction Permit
Permission is hereby r t d to Cons c ( )R pai ( )Up race( ) don
System located at �a � � �i 'f
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 permit.
Date: '�` U Approved by 1�a-
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