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TOWN-OF BBARNSTABLE
LOCATION 1 a1_��1�I'). !L�
SEWAGE # oo(o� l3�
VILLAGE I-I`m n n i S ASSESSOR'S NUP & LOT_ 13 t"iLO
UNSTALLER'S NAME&PHONE NO. CaoQw i le— Cnf*4-1?
SEPTIC TANK CAPACITY {000 �Ci� 1�-1.a �e•�s� j �
LEACHING FACILITY: (type) r1 (size)
NO.OF BEDROOMS
BUILDER,.OR.OWNER
PERMITDA'I'E: q-5'—Ot. COMPL CE DATE:-
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 any wetlands exist
Y
within 300 feet of leaching facility) Feet
iFurnished by_i�AO&J;C4 ei Ck, C-- _
CQ
PIG
�r .
No. r r + Fee
THE COMMONL ETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for Migaal bpgtem ctConotruction permit
Application for a Permit to Construct( )Repair( l�pgrade( )Abandon( ) ❑Complete System Mdividual Components .
Location Address or Lot No. d 11 al,�A Owner's Name,Address and Tel.No.
Assessor's Map/Parcel �
Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No.
e4eZ....'ifa Ehkl�n"��5 Lac 2��c(o-LE'' Z7o-..�.� Lw, --
Type of Building:
Dwelling No.of Bedrooms Lot Size Z3 I001 sq.ft. Garbage Grinder( )
Other TI pe of Building No.of Persons `Showers( ) Cafeteria( )
Other Fixtures
Design Flow a�(ltil �" gallons per day. Calculated daily flow gallons.
Plan Date K, Number of sheets Revision Date — --_-
Title
Size of k i 00 o /+ i�_eTypd of S.A.S. IVi
%
Description o 0f
Nature of Repairs or Alterations(Answer when appii able) ���'n /v 0. eA !S'Q
Zoo u 0
r
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 by s Board of Health.
Signed Date
Application Approved by Date
Application Disapproved fo the following reasons
Permit No. a3pL. t 3q Date Issued
.x �' I.�- "V. i. --N_1ilf 7,f- ri � +.. Y-.+ .�y,,.�',�i.. ' T:,..?' I - 3�! 1i..Yl•..s� i4£{a-F'lr/C,��i- Y.`\ ..'Y' Y
No. 9, f 3 q « Fee
THE-COMMON' EA. . .OF MASSAeH TTS Entered in computer:
Yes
` h PUBLIC HEALTH DIVISION.;TOWN OF BARNSTABLE, MASSACHUSETTS
I 3
ZfppYirkior' for,biopool bpotem Construction Permit
Application for Permit to Construct( . )Repair(: grade'( )Abandon( ) El Complete System O Wdividual Components
Location Address or Lot No. 1 I.1'7 Z%I k h N o`/5h r4o A Owner's Name,Address and Tel.No.
-. Assessor's Map/Parcel ;�^�3l , Q
-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
C�apeu„' E11kI�v�',t� L1_( s-•f'2t-U�zF 170,,>�, Cvare e:�•S,l �..;�,�
e�-.r-ei.-f Alt I�-r�-•,-� �-, ..�C
Type of Building:
Dwelling No.of Bedrooms Lot Size X 23 I,,u}sq.ft. ,,,Garbage Grinder( )
Other 'I�pe of Building C'a�„�,sRc,Yrl No. of Persons 'Showers( ) Cafeteria( )
Other Fixtures l
Design Flow Pod Sp 45 0 he N! gallons per day. Calculated daily flow gallons.
Plan Date - 1/ Jt Number of sheets Revision Date _
Title
Size of SeptiTrlC I{ps� 4AI ii Type of S.A.S. T�6},�,� �
Description of o21
)
Nature of Repairs or Alterations(Answer when applicable) 4�Q0�'+tkj
/o�� S✓�� �iCv�� T/�O
w Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage"disposal system
n 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 by this Board of Health. I
Signed Date
Application Approved by IA,,, Date_Y LV 6
Application Disapproved for •'a following reasons
� 6
n t
Permit No. N06 - /39 Date Issued r
Is 000 10/1 re Pi � THE COMMONWEALTH OF MASSACHUSETTS'11
r
5 ' 1 BARNSTABLE, MASSACHUSETTS
Certificate of tomptiance �£
,
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constrticted( )Rep a ed(�/ )Upgraded
Abandoned( )by AOI?r.), [✓� Orr �Qa
at ✓4 1 has been?construotel in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 010 6" T9 dated )
Installer 6 .4 Designer l
The issuance of this permit. hallJnot be construed as a guarantee that the sys earw Nfunction as designed.
Date7Olo Inspecto
No. 1 v/ - . Fee /. .
THE COMMONWEALTH OF MASSACHUSETTS
a
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS €
Migool *pztem Con5truc ion Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( bandon( )
System located at //1 JLVA&,b 0 ,.�
'>s
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 i7ld
p
��ppDate:' Approved by a/- IDS
I
Town of Barnstable
Regulatory Services
; Thomas F. Geiler,Director
BAR IM11.6, •
MAM �� Public Health Division
163g6Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 5�2 06 Sewage Permit# Assessor's Map\Parcel
Designer: J�>aW���4PECn�t^y.�E6`��rl�, C Installer: Cj�PEwIA e Cw'�
Address: 01310� A Address: �'• Zc 3
On "�"�-oo 6 ,dka &1Ab-S-e; was issued a permit to install a
(date) (installer)
�qe -''f`s-toa�y)ptic system a ► I 17 4 ^tJtJO�Y 1-�12D��j'3-i. based on a design drawn by
(address)
N
Cawv, cam Ahy►-a'.:� CLACK C& dated a of06
(designer
I certify that the sept' system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
\ H OF 4%
c
DANIELA. y�N
er'9 Signature) OJALA
CIVIL
No.46502
I c L
f 1. 1 SSA G L- S
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM`AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
L4 5
w --------- Fee--------------------
No.---------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application Ar Well Congtruction Permit
Application is hereby made for a permit to Construct ( P_), Alter ( ), or e a
Location — Address Assessors Map and Parcel
Owner Address
fly--�--�-C���`�02� --- ---------- ---�--��--------- ---------------0-�1�''1_oJ
-- - - -
Installer — Driller Address
Type of Building
Dwelling ----- -— — —-- —
Other - Type of Building---- ------- No. of Pernsons---------------------___
G -Se� Ca acit
Type of Well P Y---- -- --- --- ———
Purpose of Well---- —G '' -----
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation un ' yfficateo pli ce has been issued by the Board of Health.
Signe ——_— — — - —
te
Application Approved BY t�1 —
date
Application Disapproved for the following reasons:
---- -—--— — - -- - — - -- — -- -
_ date
- ^ —0 �-------- Issued--------- /� __-------
Permit No. C �9 5—_ ------ ---- -----
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifitate ®f Compliance
THIS IS TO ERT FY, That the Individual Well Constructed Altered ( ), or Repaired ( )
by_______ ______------ Installer
at- -— -------- -- --- -- ------ -- ----has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. -------------Dated---- =----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- ---- — --- -- Inspector---- —-- - - ---—-------
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No. Fee—
BOARD OF HEALTH
n
TOWN OF BARNSTABLE
w_
01pp[icat ion ArVell ConotructiodPermit
Application is hereby made for a permit to Construct Alter ( ), or Repair ( )an individual Well at:
--- ---- -- -
` i-Location —Address Assessors Map and Parcel
r
-- ---�r— ---Owne r ;, Address,—
f
/ 1Jc: o k ��7 G c �Z���✓ 4__
Installer - Driller .Address r
Type of Building
Dwelling -— —--- -— - ----------
Other - Type of Building---------------- No. of Persons---------------------
; C'f15'
Type of Well — ----:----- Capacity---- C-;o
-------------- -------------
Purpose of Well--- -7Oe_� G,Ay��L
i
I
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate .of Compli Ince has been issued by the Board of Health.
Signed-
Application Approved By — -----------—— // -- ---
date
Application Disapproved for the following reasons: ---- --- - --
I
date
Permit No. / —_— Issued-------J�_/---------------------_____
i date
i
BOARD OF HEALTH
TOWN OF BARNSTABLE
C ertif ttate ®f ComPCiance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ) Altered ( ), or Repaired ( )
Installer
` at- -— ---------- -- --- ------has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. ------------Dated----- ------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
I
DATE--------- --- — Inspector---- —-- - - --- --------
_
- BOARD OF HEALTH
TOWN OF BARNSTABLE
`. �eCC �on�tructton�ermtt
f No. '� _— �__� Fee-----__----__
t
Permission is hereby granted ' —
I� to Construct ( G)''�Llter ( ), or Repair ( ) an Individual Well at:
1 No. -- —v11 4 q, n -� -Street ,�T'
fas shown on the application for a Well Construction Permit 4
No.-- -- -- ated-- ---——=------------------------
--
Board of Health
DATE
F
l
�ofTHeTo� "� No. --
y�P Off ICE OF THE BOARD OF HEALTH
s '"ate
e BnHaST LE, o, OF THE
9�O M6 ��0 S
a 3 TOWN OF BARNSTABLE, l ASS
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E GE D1SP0, AI /PE M1T
Permission is granted to _':`_�`� �'_ ___________ _ __ •' ___ to construct _ ' 1
Upgn the Premises of Sketch
l 9n4
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100 or more feet from any source of wa<WrV/supply
20 feet from buildinVIrin
ttJJ
10 feet from oper
---- Hedo Officer.
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C.O.
SAVE BIRCH TREE X 66,g
IF POSSIBLE
R EXISTING GREASE TRAP +67.0
KNOCKOUT ELEV 62.57
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