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Home My WebLink About0251 PHINNEY'S LANE - Health (2) 251 Phinney's Lane Centerville A = 230 — 162 /11 S M EA®® No.2-153LOR UPC12534 smead.com • Made In USA ~ FlfAtl�Nif9SPA000C�1lNE SFI �SFIPII�N►� sou y�w•S�OG'�ot� TOWN OF BARNSTABLE E . 0 LOCATION ` `� '`� AGE # 3 I b VILLAGE Le IA&:&,2SI\� � ASSESSOR'S MAP & LOT d'!0. 16 a- INSTALLER'S NAME&PHONE NO. S63 SEPTIC TANK CAPACITY (l Q 0 CFSe k'�>COX LEACHING FACILITY: (type) a, —(size) , ig2O t/'Y NO. OF BEDROOMS BUILDER OR OWNER PERMPI'DATE: S �I \ t 5 Y - COMPLIANCE DATE: � Separation Distance Between the: J Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1 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 f t of leaching facility) ° —Feet Furnished by • 3 Q�cIAL A Q 47> G A-D Cox ?2 ?2 No. ! Feer- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 3pprication for �3i! 5aY *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No.< �(� �c Owner's Name,Address and Tel.No. Assessor's Map/Parcel �`� ��,t ' `e'�v ��th,C� � ` Installer's Name,Address,and Tel N Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms J 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 ex Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) AA J &w0 LeGC,L. -k�ci,,\ ZAZ 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 ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been i ed by this B az of Health. Signed Date t I /(y Application Approved by_ - = Date Application Disapproved for th ollowing reasons Permit No. Date Issued No. � - ' Feer— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Diop gal *p$tem Congtruction Permit Application for a Permit to Construct( )Repair )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.ask Owner', 'lame,ame,Address and Tel.No. � Assessor's Map/Parcel as ` c� - /6 Installer's Name,Address,and Tel Np. Cj, G Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _S 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 2 Type of.S.A.S. Description of Soil Nature of Re airs or Alterations(Answer when applicable) AJJ roo) Leao-, i"^,Ct,-, NEXY 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 ental Code and not to place the system in operation until a Certifi- cate of Compliance has been ' s ed by this ar of Health. J Date i r Signed ti Application Approved by Date �" Q(-9 Application Disapproved for th following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( //upgraded( ) Abandoned( )by M CA-C r S\A G.M S at ne,- has been constructed in accordance with the provisions coif Title 5 andUhe or Disposal System Construction Permit No. — dated Installer S� �\ r-\ \`cT,�/�-V� Designer The issuance of th5&petm shall construed as a guarantee that the sys m wjlLfunction as designed. Date CILb Inspector ———— No. � 3� . Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mizpozaf *pgtem ongtruction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at �� 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 -1 z r , 10/9191 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) Y ` i • b hereby certify that the application for disposal works construction permit signed by me dated / �� ,concerning the y meets all of the property located at r' �� L following criteria: There are no wetlands located within 100 feet of the proposed leaching facility �Therc are no private wells within 150 feet of the proposed septic system • There is no increase in now and/or change in use proposed There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the r proposed leaching facility will nDI be located less than fourteen(14)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) / B)Observed Groundwater Table Elevation(according to Health Division well map)s SIGNED: DATE: �CY 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:cart G r�6L i TOWN OF BARNSTABI E LOCATION AGE # VILLAGE QA�(r�1\��'�_ ASSESSOR'S MAP& LOTSa— INSTALLER'S NAME&PHONE NO. SEpI'I.0 TANK CAPACITY `S1L�C) ��` �c,✓�l/L �X LEACHING FACILITY: (type) �� (size) fOF BEDROOMS (10 n B.UII:DER OR OWNER PERMITDATE: a L�Y - COMPLIANCE DATE: Se.Paration Distance Between the: Mazi:ri:um Adjuste&Groundwater Table to the Bottom of Leaching Facility V Feet Private Water Supply Well and Leaching Facility (If any wells exist ::on:site or within 200 feet of leaching facility) _�( A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 f t of leaching facility) ',�—4eet Fui�ii x,'hed by �L L xog SL xo � �Y oot hL nv . C