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LOCATION 7 -� L SEWAGE #
VILLAGE / �q '� _ ASSESSOR'S MAP& LOTt 9- OS8-oo3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) C e rya (size) / �C
NO.OF BEDROOMS
BUILDER OR OWNER Ctmm
PERMITDATE: �" �-Lt " `!9 COMPLIANCE DATE: 1-!Z-:�T
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 feet of leaching facility) Feet
Furnished by /
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
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PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
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application for �Mizpaar *pztem Cow5triuction Permit
Application for a Permit to Construct Repair( )Upgrade( )Abandon( Complete System El Individual Components
Location Address or Lot No. y 40
L D Owner's Name,Address and Tel.No. 40 8 y
g 3
Assessor's Map/Parcel L 0 •
Installer's Name,Address,
�and
d-Tel.No. Designer's Name,Address and Tel.No.`
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil _Q L 1J
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 i by i oard of Health.
Signed A dzw e 40 Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
•,ram" I' � v ,. — v¢a �./.� ,• .� �F ,.� _ _
Fee It)h j
# CIA SSACHUSETTS Entered in computer:
TIE CO�.MONWEALTN s
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PUBLIC HEALTH DIVISION -TOWN O'F BARNSTABLES MASSACHUSETTS
01ppYication for �Bigogal *pgtem Congtruction'Permit
Application fora Permit to Construct Repair( )Upgrade( )Abandon(OFKomplete System El Individual Components
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Location Address or Lot No. 144 01,V A4 Owner's Name,Address and Tel.No.
Gr �cc �►�p is i! `J
Assessor's Map/Parcel cel � �y�J 1' 1 _n-i R j Cy
+-"" 1.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: 1 /;
1 Dwelling No.of Bedrooms 3 ¢ Lot Size j -1 sq ft. Garbage Grinder*( V
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow _ gallons per day. Calculated daily flow gallons.
Plan Date 3 14 Number of sheets i� Revision Date
' = Title 1 0
Size of Septic Tank 1560 60 1y;fL Type of S.A.S. 1,�
-Description of Soil SE:e., QL,�
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 issue bythis-Board of Health.
Signed e 00 Date jr I t
Application AppXoved by 7 Date
Application Disapproved for the following reasons
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Permit No. .�... Date Issued
__:_... ----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
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\ �BARNSTABLE, MASSACHUSETTS
Certificate�of Compliance__,
THIS IS TO'CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by i
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. q 1; dated
Installer Designer
The issuance oftA Is permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
i
———————————————————————————————
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No. O� - Fee j
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THE COMMONWEALTH OF MASSACHUSETTS s
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Iigpogal *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon(, )
System located at
A,
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: �Approved by
TOWN OF BARNSTABLE �� C,
LOCATION 7 `�'` s SEWAGE
VILLAGE `� �` '' _ ASSESSOR'S MAP & LOT_;'I 7 9- d50 003
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS �s
BUILDER OR OWNER 746� CZM t
PERMITDATE: S- �-� �19 COMPLIANCE DATE: ..— !g
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 feet of leaching facility) Feet
Furnished by
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