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WSPON RIEN'�A E AND
J TOWN OF�BARNSTABLE4 .
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I- ..ems
r : � [ Buildin ermit Application
Project Ad JL r '
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,Owner �. �� ,�li? � Address
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;'Telephon , .--
,Permit Request
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Total 1 Story'Area(include 1 story garages&decks) square feet, f
Total 2 Story Area(total of 1st&2n stories) square feet
Estimated Project Cost $ a°
Zoning District Flood Plain 'Water Protection
Lot Size Grandfathered ?
Zoning Board of Appeals Authorization Recorded,;
Current Use Proposed Use
Construction Type
Commercial [ Residential
Dwelling Type: Single Family � Two Family Multi-Family'
Age of Existing Structure Basement Type: Finished
Historic House
Unfinished
Old King's Highway
Number of Baths No.of Bedrooms
Total Room Count.(not including baths) First Floor
Heat Type andFuel Central Air Fireplaces
Gara e: Det
ached.tached. Other Detached Structures: Pool
Attached Barn
.....4 - -
None Sheds
Other
t Builder Information
Name Telephone Number
r -
Address License
Home'Improvement Contractor#
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS,
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE `%�`�" S�✓ ✓� DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
LOCAJION SEWAGE PERMIT NO.
VILLAGE
is
No
INS 11 R'S NAME i ADDRESS
S ft
lY� R U DE R OR OWNER
DATE PERMIT ISSUED
VA.TE COMPLIANCE ISSUED
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No.......lJ�... ...... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
:n7...........OF..........
I _,] - _e
for Uhipusal Works Tuntitrurtion runfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
I System at
Los 'on-Address or Lot No.
a = ........ ---------- ress
d v
dd
U Type of Building Size L� X_2a�q. feet
Dwelling—No. of Bedrooms-- ............................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ........................... No. of persons....._.............._....... Showers ( ) — Cafeteria ( )
Pa Other fixtures .....................--•--•••-- -
W Design Flow................ 1-'�..................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capac�.,Ofo.gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter--_-___-______--__-- Depth below inlet......_._..... .__ otal leaching area___.._.. ._..-_sq. ft.
Z Other Distribution box ( ) Dosing tank 6
Percolation Test Results Performed by........................................................................... Date.......................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........_...............
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•--------- . ............................. ............ ................
O Description of Soi b F. —.... ..---- .... w .
,p '�� ` C
v ---------- --- d - -- --- C f� 5 T
W ,
x ----------------------- •------.... .........---•-••-----.
U Nature of Repairs or Altera ' ns—Answe when applica e.- ,� -- --------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e bo rd of health.
----- --•-:--•--------------------------------•-• ••- `..,�..
/1 ate
Application Approved By......... f _ . j . .. . _,
Date
Application Disapproved for the following reasons-...................................... --------••--••---•......_.._....-----• a.t e..............
•..................................•------•--------------------------•-----.........-••--•--•-------•------------------------•------••-•-•-••----•--•-•---•-•........................................
Date
Permit No......................................................... Issued.--.. � �- ----••---
�,/� a-i Vole --
____ ..--_-_.........-------------__--- ----------------------------------------------------------------------------------�
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® QF HE H
4 ...' .... oF....... --------
Aptiration for Dis#utia1 Works Tonstrurfian rruti#
Application is hereby made•for. a Permit to Construct ( ) or Repair ( ) an Individual Sewage 'Disposal
System at
........... - .............................
-
" ;L ;'on,Address or Lot No.
..............................................
W dress a
a f :• . .. .... ................. ......
p, ddress
U Type Dwelling ding Size Lo q. feet
of
g—No. of Bedrooms.._fl-
PL4 .................................Expansion Attic, ( ) Garbage Grinder ( )._.......... No. of persons............................ Showers
Other—Type of Building ________________ p ( ) — Cafeteria ( )
d Other fixtures . --------------------------------------------
------------------
---•------------------
W Design Flow................ '�..V.._...._._...._...gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capaci -gallons Length................ Width---------------- Diameter............._.- Depth................
x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching`area:............-....._sq. ft.
Seepage Pit No ... Diameter ... ... Depth below inlet...., otal leaching;area... sq. ft.
Z Other�Distributior} ox' ( . )'T¢ Dosing tank ( ) "` „ „• '"�"' „ ? .
a Percolation Test Results,, . PgTf ormed by.......................................................................... Date......
,4 Test;;Pit No. L_: c:..........minutes per inch Depth of Test Pit...:................ Depth to ground water...._.......:,..........
G%, Test Pit No. 2................minutes per inch: Depth of Test Pit_................... Depth to'ground water.__._._.__..____._........:;
°- r -- - '----- ................................-
4: .
Descri tion_of`Soi _' """" '""
x
P � ... . fit -.
U ------.. ............ '-
vW _
--
Ux Nature of Repairs or Alterations—�Answe when a lira -- ... " ..
p�... .................................................... ................................................., ; '. . .
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—T e.undersigned further agrees not to place the system in
operation until a Certificate of Compliance has,,b� ���Y, bo rd of health, i
:.,
-- ate #
Application.Approved B l ._
.
• i .Date
xa Application.Disapproved for the.following reasons-...................................... ........................................................
.......................................................................................................................................................................................................
Date
Permit No.................•-•-•---•-----------_: Issued----•---........._...
to. .................. Date------•---•-------•--•---._....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
:, O F. .. ...........
CFI I T RTIF , at the Individual Sewage Disposal System constructed ( ) or Repaired
b ................................................ •. -•-- --•-
has been installed in accordance with the provisions of Article XI The State Sanitary Cgde a described in the
applicctt'ion for Disposal Works Construction Permit No....
............ ,3----------- dated --.�. 7 ........._..._...
THE ISSUANCE OE THIS CERTIFICATE SHALL NOT BE COINST !E AS �► �9ARANTEE THAT THE
SYSTEM ILL F C`PI.O ATISFAC'TORY.
DATE......•-•---- -•-.... .. •-• •..._ ................... Inspector .....: . ...... ...... ..............
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THE COMMONWEALTH OF MASSACHUSETTS
BARD OF HEALTH
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s FEE... r............
i` ]a a or � r ton rrmi�
Permission is hereby grant e --- - ---. elL.. ��......................................................
to Construct ( or pair ( an/Individ wage Disposal Sys Y .
at
Street
as shown on the application for Disposal Works Construction Per: o.._. Dated.... " �_- ......---
....
/ '(- .
Board of Health
DATE:... _
FORM 1255 HOBBS &•-WARREN, INC., PUBLISHERS
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