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Home My WebLink About0020 AUDUBON CIRCLE - Health 20 AUDOBON CIR. , CCN7ERVILLC - No. 4210 1/3 ORA. ESSELTE 10% O A O O r, � �No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pp1tratton for Mtg oml *p$tem Com5truction VErmtt Application is hereby made for a Permit to Construct( )or Repair( ✓jan On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. ab &80 bur, C,CA f_. CL- -ote 'CV.. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms_ Garbage Grinder Vo 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 Description of Soil Nature of Repairs or Alterations(Answer when applicable) A8J 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 issu kby this Board of H rr Signed Date / 14 Application Approved by Application Disapproved for the fol owing reasons Date Issued Permit No. ��ol — :✓*"�+" ..3`•- ...r,,:u„.., -.,. , ,.r'°w'h.-�.l�v'.�'s''...'.w�%�4.;iN..,.,, :w�r.Y.�"^r-s.,v*:007r._.� .-.+.,4... .a..�..iw,y..-,. .-...,.-..va-'� ,.r+ r-� ... .. .._;a - ,.. '4+:.�..w No. Fee THE COMMONWEALTH OF MASSACHUSETTS 14UBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Tippitcation for Migpogal *pgtem Congtructton Permit Application is hereby made for a Permit to Construct( )or Repair( uo�r an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. �- a� U (30r" C:r Ck e_. �W(� 'c vc r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. iS Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building No.of Persons Showers:( + Cafetiria( ) sOther Fixtures Design Flow gallons per day. Calculated daily flow gallons. r Plan Date Number of sheets Revision Date Title Description of Soil .� Nature of Repairs or Alterations(Answer when applicable) A d rf L kc-r _-Nnr" V � 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 iss by this Board of H r Signed t! Date /49 7 /q6 Application Approved by _. Application Disapproved for fol owing reasons -. p Y Permit No. /l Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced on by SCC* Vl- .`t for Cc,gn-, 6-iC,IX V C K f te has been constructe in a dance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated - Use of this system's} neonditioned on compliance w' h the pro isions set forth below: ef _ v 'V F'/ No. 9z, — Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogal *pgtem Con5tructiou Permit Permission is hereby granted to S C 0 A M to construct( )repair( L-f an On-site Sewage System located at Ay d O�Un Ci r /gpAkt.rVl\\ 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. All construction must be completed within two years of the date below. Date: �I / �z Approved by �� CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WOItKS CONSTItUCTION PERMIT (WI'I'IIOU'T DESIGNED PLANS) Cz I, � G'` Ld�\, , hereby certify that the application for disposal works construction permit signed by me dated �'�a u (5 (p , concerning the property located at o bc) \ C- CaA- "Atsall of the following criteria: J • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE:e-11-1 ;:j�7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. s a _< TOWN OF BARNSTABLE + LOCATION ® C) /()d 0 bM C i r SEWAGE # � VILLAGE fie ASSESSOR'S MAP &LOT16 INSTALLER'S NAME&PHONE NO. � -ti �s �7 S �� 1 G,_1 SEPTIC TANK CAPACITY C= w 1 U O y-- LEACHING FACILITY: (type) a �, ..� -=-�.kc�— (size) 'Q NO.OF BEDROOMS :3 BUILDER OR OWNER � �7 PERMITDATE:I I�� I C1 W COMPLIANCE DATE: 1 / G i0 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility M, u4v eet 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 leachin facility k � � Feet Furnished by {�i I L7 A -vo 5, Ll /A �-o Z) 4 � �^�� LO PERMIT U O. ILL-AGE INST E �'A E E 5UILDE 5 Q b, D DRE SS D-LTE PERKA T ISSUED D ATE COMPLI W ACE ISSUED : 44 _,1— 71 a ,.� �� ' �I � y� o . . ,��