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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rppticatiou for Mi5po5al 6p.5tem Cou5truction Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete System 9 Individual Components
Location Address or Lot No.S')-? ,f1A-A\\f\ She$ Owner's Name,Address,and Tel.No. Q' 'L\\,r\S 0 S
S ?? MAAf v� s�r,1�e'r f�yAA�.1s
Assessor'sMap/Parcel ,� -7?- 1 . .94 4
Installer's Name,Address',and Tel.No. c7 Designer's Name,Address and Tel.No.
O0
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder
Other Type of Building Qe No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
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)
fg�M EA ,- y`
Date last respected:
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 Certificate of
Compliance has been issued by this Board Qf Heakih
Sign Date 10
Application Approved by a Date
Application Disapproved by: Date
for the following reasons
Permit No. - Date Issued lei
�__-__ -------- _
eel'1 No. F (�cU
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH :DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppYication for Digpogaf *pgtem Con5truction Permit
Application for a Permit to Construct O Repair Upgrade O Abandon O ❑ Complete System X Individual Components
Location Address or Lot No._�'7_? fV\+A \N 9 r Owner's Name,Address,and Tel.No, wYZ� S p S 4 cj2 eT'
r rte 7'Assessor'sMap/Parcel302 ,.. S63 -7'?_ 1
Installer's Name,Address,and Tel.No. g Designer's Name„Address and Tel.No.
TV-\ T' J C S i4r\d'10��
T7 •� •Z.Boo
Type of Building: -
'"� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of BuildingQ(?ST-v_,,r� No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
1
Nature of Repairs or Alterations(Answer when applicable)Vlpel a_gQ_De 2 V etc vw^,
Date last inspected:. . A
Agreement: '
The undersigned agrees to ensure the construction and maintenance tof the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and riot to place the systemin`operation until a Certificate of
Compliance has been issued by this Board of He kth
Date I
� wAppication� pproved b Af
O � Date02/2
Application Disapproved Disapproved by: ` Date
t + for the4bllowirig'reasons
y i
Permit No. Date Issued
s THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS -
Certificate of Compliance
THIS IS TO CERTIFY,'that the On-site Sewage Disposal System Constructed ( ) Repaired (,K Upgraded ( )
Abandoned( )by c-, o
at S 7 7 M 4 1 vk "S'f v2 e 2 1 `� ha)/be�re�)/cp-nstruc e i��p rdance
r'
with the rrovisions of Title 5 and the for Disposal System Construction Permit No.(Y(iT/((� (/I dated
Installer 0 Designer
#bedrooms Approved de ' ' flow gpd
The issuance of this permit shall of be construed as a guarantee that the system i1v4 1 funct' n psi ed.
Date // /0 / Inspector
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
1wigpogat i§pgtem Congtruction Permit
Permission is hereby granted to Construct ( ) Repair (X ) Upgrade ( ) Abandon ( )
•i
System located at S -2 ►M�'� v- S ee.-T— �W v%.n'N, S
A
i
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 �e co plet d within three years of the date of th' �rmr a
Date Approved by U" ,