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Home My WebLink About0022 BREZNER LANE - Health 22 E L+ A=230=-024 i UPC 12534 No.2-153LOR HASTINGS, MN' .�� No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplication for Migpogar *pgtem Congtructiou Perron Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) 0�Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. r 2� Ale,Z�e�'t `i'I, ve eoo Cvl_�� Assessor's Map/Parcel CeeArkli /eO Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 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 / u�®!�✓ Type of S.A.S. l e er3e ' _ Description of Soil '/_s'��.t'1/�i/�/'� Nature of Repairs or Alterations(Answer when applicable) /� � 6.&/jam 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 issued th' d f Health. Signed A r, Date Application Approved by Date 91" r' Application Disapproved for the following reasons Jt Permit No. Date Issued Zia t� No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Zipprication for Migogar *pgtem Congtruction 3dermit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) Complete System ❑Individual Components, Location Address or Lot No. Z Al Z�e Zf l h Owner's Name,Address and el.No. Z e l� vefeo-# G� �•�� Assessor's Map/Parcel Ge1�"il eo Installer's Name,Address,and Tel.No. �l Designer's Name,Address and Tel.No. ,80��oGr�Xti Go�s� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(� Other Type of Building 4 51 -eNce No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow !/D 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 `/— 1V rjA l Zel5 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 issued th' d f�Iealth. Signed Date Application Approved by _ Date r' " ,$e> Application Disapproved for the following reasons Permit No. '� Date Issued '' ---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,th t the On-site§ewage Disposal System Constructed( )Repaired(--)Upgraded( ) Abandoned( )byD/ at Z Z YrG Zyi 'r' C e P'1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ef dated 9l 1 Installer Designer The issuance of this permi shall not be construed as a guarantee that the system will function as designed. Date C Inspector Zz� No.�Q '' ��f —————————————————---� 'Z' / Fees THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1=igpogat *pMe ( )ongtructton Permit Permission is herebyranted to onstruct Repair( !!)__UCPgrade g ( ) P Abandon ( ) System located at 4 , Lem Xv�Ile 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 becompleted within three years of the date of th rmit.Date: � 7 " �!" % IS" bK ,_W1if�'r'G?� ' t 0/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) �hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at Z 2 meets all of the following criteria: ✓ There are no wetlands located within 100 feet of the proposed leaching facility V There are no private wells within 1-40 feet of the proposed septic system /There is no increase in flow and/or change in use proposed There are no variances requested or needed. Iff the proposed leaching facility will he located within =50 feet of anv wetlands, the bottom of the proposed leaching facility will =be located less than fourteen (la) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) 7�✓ B)Observed Groundwater Table Elevation(according to Health Division well map) �0 SIGNED : DATE: 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]. q:health folder.art 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT ENGINEERED PLANS) 1 hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at meets all of the following criteria: • There are no wetlands located within i00 feet of he proposed leaching facility • There are no private wells within !`0 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • if the proposed leaching.-ac;iity wiil;e iocated within:50 feet of anv wetlands.the bosom of:he proposed leaching faciiity will❑4S be:ocated!ess than fourteen f,:-1 fee:above:he mas:mum adiusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(accoording to Health Division well map) SIGNED: DATE: 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]. 4;hedth folder.cent r Y J TnJIZ 4` >4-a1,0� � 4�c�►.t z&/�S� I c j 5� O O doi I � h I 1 W h11 f7or� I � TOWN OF BARNSTABLE _ LOCATION 2� �,�� , SEWAGE # vti.LAGE �e�7'r/�vlr�� ASSESSOR'S MAP &LOT 2 3e-a - / INSTALLER'S NAME&PHONE NO. �D11`laLOl 7 7/'9��9 SEPTIC TANK CAPACITY Sacs LEACHING FACILITY: (type)1 Cf� r.r U� (size) NO. OF BEDROOMS 3 BUILDER Ol PERMIT DATE: �/~�S COMPLIANCE DATE: `� - 7 Separation Distance Between the: s f Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist 4)/4 Feet on site or within 200 feet of leaching facility) exist Edge of Wetland and Leaching Facility(If any Feet within 300 feet of leaching facility) Furnished by TOWN OF/BARNSTABLE � 4 X d1 e-/l l�t, SEWAGE # VILLAGE CeiI7r-11.111 i°- ASSESSOR'S MAP & LOT - INSTALLER'S G--dZy INSTALLER'S NAME&PHONE NO. &LO lOZl SEPTIC TANK CAPACITY ICW 4,L LEACHING FACILTTY:.(type).� �� ,.r U� (size) /01x3o' ' NO.OF BEDROOMS 3 / BUILDER O OWNE PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility St Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /)14 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) -`—A Feet Furnished by � I :e- o O I N0IVA yap I i A6 mol f i