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Home My WebLink About0029 COOLIDGE STREET - Health _ 29 Coolidge' ls� U I T _- - - --- - — LTA = 035 038 -- --- — - -- - TOWN OF BARNSTABLE LOCATION �LA C 4 Sr SEWAGE # Z VILLAGE ( V'U�G— ASSESSOR'S M,APP&& LOT INSTALLER'S NAME&PHONE N6.—= -✓ SEPTIC TANK CAPACITY '� -SCCO VlNb"' LEACHING FACILITY: (type)" ✓--:VLC5 (size) 16'7< NO.OF BEDROOMS BUILDER OR OWNER T\` `/0 PERMITDATE: J L Z COMPLIANCE DATE: 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �,P'� a . s�f o ® ' I •�. -� d,,E yov,� ® � � f�� o No. Q< Fee THE COM ONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mi!5paar *p5tem Construction Permit Application for a Permit to Construct( )Repair(Ylllu"pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. QL C� GOO y ��5—r ^ Owner's Name,Address and Tel.No. Assessor's Map/Parcel 0 3 Installer's Name,Address,and Tel.No. a Designer's Name,Address and Tel.No. Ae a 09 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 73 a gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 57�1 sue- %l»[> Type of S.A.S. =A..,4 L re a, r D C Description of Soil 0 14rev Nature of Repairs or11 Alterations /(AAnnsww/er when applicable).. SStN S� (� 1 1�4 6 �9-✓ A"V_ `'t ` o w Sf 0,S o 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 no o place the system in operation until a Certifi- cate of Compliance has been issued by this Boar .H t . SignedI Date /' —F Application Approved by Date � e� Application Disapproved or the Tollowing reasons Permit No. Y.7.° o Date Issued � No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for 13i5pozaf *p6tem QCongtruction 30ermit Application for a Permit to Construct( )Repair(l Upgrade( )Abandon( ) ❑Complete System ❑lndividual.Components Location Address or Lot No. Qt G 001«/ Owner's Name,Address and Tel.No. Assessor's Map/Parcel Y Installer's Name,Address,and Tel.No. . Designer's Name,Address and Tel.No. lAr�t c (Z Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures x Design Flow � gallons per day. Calculated daily flow 33 gallons. Plan Date Number of sheets ., Revision Date Title Size of Septic Tank 15:c<,50 1,000 Type of S.A:S. LTA-yo h Description of Soil qvw Nature of Repairs or Alterations(Ans er when applicable) �'tN K� W t� �-T'�ti C }(?j Yl lY1P.y c.� '^ t O - Sr` o eK r S t Date last inspected: ti 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 no o place the system in operation until a Certifi- cate of Compliance has been is�this Bo aH fit '"' Signed Date / Application Approved by Date Application Disapproved for the following reasons 1 Permit No. Date Issued ----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT tha he Ot�si - a e Disposal,System Constructed-( )Repaired(V)Upgraded( ) Abandoned( )by -e v at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7-11 datedT.� Installer Designer The issuance of this permit shallc of be construed as a guarantee,that the system viilllffuncti n Date as designed. / Inspector V V ————— r f No. �- —�---------------- -------�—Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Qi9;Po!5ar bp5teut/Con6truction Vermit Permission is hereby granted to Construct( )Repai{ Upgrade( )Abandon( ) System located at �--Gt [�l \t S dTy 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 2ofthis a it. Date: �r-` "'� / Approved b I i 4 � I 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 DESIGNED PLANS) I, ��n� ems 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 within 300 feet of the proposed septic system @ 1 • 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 V • There is no increase in flow and/or change in use proposed `v • There are no variances requested or needed. SIGNED : DATE: — 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]. j:cert .. . . .. d • ` L � i