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HomeMy WebLinkAbout0106 PINE LANE - Health 106 PINE LANE, OSTERVILLE A=118-070 r 1. a P� o TOWN OF BARNSTABLE LOCATION /%O Axe, A, SEWAGE . VILLAGE �5 �lJ� !Y% ASSESSOR'S MAP & LOT --07 INSTALLER'S NAME&PHONE NO. ���I�1Cor�s�` SEPTIC TANK CAPACITY l Dt c5� LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNERrP�/yt° PERMTTDATE: COMPLIANCE DATE: ilk Separation Distance Between the: is Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well 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 N _ - -O I G® � w �� 70 No. � Fee 1 E COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes , PUBLIC HEALTH IVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2ppitratton for Mtgoar *pgtem Con5trurttoli Vermtt Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) L Complete System ❑Individual Components Location Address or Lot No. O ), /� Owner's Name,Address and Tel.No. v / i A,. �4r� ,d Assessor's Map/Parcele- ie elm. Q Jj� Installer's Name,Address,and Tel.No. /7 Designer's Name,Address and Tel.No. &e & 7 71 3� Type of Building: Dwelling- No.of Bedrooms Lot Size sq.ft. Garbage Grinder #,.Other Type of Building C ENO.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //e 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 Nature of Repairs or Alterations(Answer when applicable) 7 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 Bo d of Health. Signed - Date Application Approved by. Date — Application Disapproved for the following reasons d Permit No � Date Issued '' `� TOWN OF BARNSTABLE LOCATION &71 Aft 7, SEWAGE # 7 33 VILLAGE ©✓'1Vry%'`///e ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. C �f�� 1Cd�57, 17/�-Q39� SEPTIC TANK CAPACITY f Dc7 .5T LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNERp�� I ` � PERMUDATE: COMPLIANCE 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 (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by f r . 00 Al. qj z ' 0.36 6?47 :k ctq-76 i � ^��9 �� M 710) No. !__ ''� Fee E COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH (VISION -TOWN OF BARNSTABLE,,MASSACHUSETTS 01pprication for -Mfgpogal *pgtem Construction permit Application for a Permit to,Construct( )Repair( )Upgrade(✓)Abandon( ) m Complete System ❑Individual Components Location Address or Lot No'''; y '1 f� Owner's Name,Address and Tel.No. Assessor's Map/Parcel /�"ate �y'✓�^ / r' •-O5 G/7v / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �j6f�LD1fe�'Df?�s�; 7 �%- 39 Type of Building: O Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building C f9G'teio. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /l - gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Titles Size of Septic Tank /v`rDO :'' Type of S.A.S. 4- Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: OW }Y 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 y t i Elrd of Health. Signed Date ✓�/Z / � Application Approved by _ _ Date k- - e Application Disapproved for the followingreasons Permit No. + Date Issued '/W:'—__ X;jrZ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ✓jam Abandoned( )by A91 ZZ41/�/ cDf%ST. at h ben constructe maccordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated Installer Designer The issuance of this permit shall got be construed as a guarantee that the sys ill fun ti esigned. Date h 7 y`7�'d' Inspecto No. -------------------- Fee-------------------------------- ee---- . s THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS- Mi5po5ar bpftem Cone;tru tion Permit Permission is hereby granted to,Construct( )Repair( )Upgrade( bandon( ) System located at /� /"/ Ve 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 th✓ Date: ''� A roved b PP Y =.. , l I � J N EN N-1 a Z 1t 4 �• C-Y y l 0 I . L r `/ 10/9197 Be Us ed Fo r the Re pair air Of Fa iled NOTICIJ. This Form Is To P Septic Systems Only. r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT; ENGINEERED PLANS) Zn'/-rT- G�o��Za{f��, Iierebv certify that the application for disposal works' t signed by me dated . /Z�G �� , concerning the construction perms g , located at �`7 �" meets all of the property following criteria: Vro ' ere are no wetlands located within :oo feet of:he proposed leaching facility ere are no oriva[e wells within l o :'eel;of:he or000sed septic system ere is no increase in :low and/or:range in lse or000sed �Iere are no variances requested or needed. If the proposed feacaing lac:iiry'�iil �e iocatec-within ==o feet of.anv wetlands. he borcm of:ne or000sed leaching faciiity will not,:;e :ocatea less :han .'aurae n t :-} lee:above the :naxnun adius. c groundwater table elevation. Please complete the following: o A) Top of Ground cievation(according:o theeEngineenng Division G.I.S. nap) B Observed Groundwater Table:Elevadon(according to Health Division well map) f/' s DATE: =/ SIGNED: A s 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]. IF hum Won.M _