HomeMy WebLinkAbout0051 BLACK OAK ROAD - Health 51 BLACK ®AID ROAD
Marstons Mills
A = 1.01 — 066
TOWN OF BARNSTABLE
LOCATION i���C,6� `� . ' SEWAGE# ,;b S 3,?C
VILLAGE ASSESSOR'S MAP&PARCEL 0
INSTALLER'S NAME&PHONE NO. ,Sc,o,A S�r
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) a/�� (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: 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) P¢dr; =ar 'Feet
FURNISHED BY
- � 1,� �C,
a I c c� F�a 4Q �.
/s --3� �
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYication for Disposal 6pstem Construction hermit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) El Complete System ndividual Components
Location Address or Lot No. ! ` ' c�LVL Y- Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel (VI 0. ram '` 5 \0 M �U� G cc, ,
In ll�er�s rl e,Address,and Tel. o
N S O`J F�v esigner's Name,Address,and Tel.No.
h bal
Type of Building: ���'' a
Dwelling No.of Bedrooms In. Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
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) qQ� M j sN..e V LN
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 Certificate of
Compliance has been issued by this Boar Health.
Si Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No., f 3 g Date Issued
NJ. � Fee (f[/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for -Misposai 6pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ;D/ndividual Components
Location Address or Lot No. S` Q\c�( - G A V, 2 Owner's Name,Address,and Tel.No.
M a(-b v^I (`s, � '3 "'Co M
Assessor's Map/ParcelS(" ( (�
In taller's e,Address,and Tel No. - ` (I 'Designer's Name,Address,and Tel.No.
ku C- 1 1 r
Type of Building:
Dwelling No.of Bedrooms �� l/L Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.requiredlI gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ®a^t G ti Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) L\(�
Date last inspected:
Agreement:
The undersigned agrees to er_sure 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 Certificate of
Compliance has been issued by this Boar Health.
Sig d Date
Application Approved by Date
t
Application Disapproved by Date
for the following reasons
Permit No.� � " 3 <' -7 Date Issued 311 �
--- -- ---------------- ------------- ---------------------------------------------'----------------•------------------------- . -.-
J r THE COMMONWEALTH OF MASSACHUSETTS
t---- BARNSTABLE,MASSACHUSETTS
' Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V/) Upgraded( )
Abandoned( )by
at T �, 1 Q A�4 9 S (dl 1ils been constructed in accordance 1
with the provisions of Title 5 and the for Disposal System Construction Permit No.X/5"" dated
Installer O CX'j- Designer „
#bedrooms Approved design floyv 4—'' and
9 r
The issuance of this permit shall not be construed as a guarantee that the system wi fun on as designed
Date —1 J Inspector
- . ------------------------- ------------- ------------------------------------ - v h -
3� Fee �
THE COMMONWEALTH OF MASSACHUSETTS
(�I .« PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction 'ermit
Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( )
System located at ��_ ( ,'c� lU r\ en; ,,S
and as described in the above Applicat-on for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be •omploted within three years of the date of this permit..
Date �� �j / Approved by 1� "'3
L 0,4C A i R d.� h S I IV A G E PERMIT iT q0.
VILLAGE P �`
' I H S T A ER'S A & ADDRESS
0 U I L D E R OR OWN ER
75 �VA I X_
DATE PERMIT ISS'UIED
DAT E COMPLIANCE ISSUED �,gq
o �