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Home My WebLink About0330 ROUTE 149 - Health MARSTONS MILLS 33 !Rp ,t qq1 I � No. ` `J ` Fee THE COMMONWEALTH OF MASSACHU ETT Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTAB s MASSACHUSETTS Yes 01pplication for Miopogal *potent Conkruction Vermtt Application for a Permit to Construct impair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 31-0 6vnlif 1,)el Owner's Name,Address and Tel.No. Ddt��9/Je OX Assessor's Map/Parcel D?$ O3� 3D Ca`0/ 12,1 Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms L/ 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 / Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �.�/� 15X/S1/1zU L A V-.0adlS GC/"h4 Sm.a � ��5'Of LAB S T 2 - yid X g A 2 "zl1''5 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 this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued - TOWN OF BpRNSTpBLE �✓G r 3 D �o r,.� SEWAGE # LOCATION ASSESSOR'S MAP & VILLAGE INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY (size) � LEACHING FACILITY: (tyPe) --- NO.OF BEDROOMS y / BUILDER OR OWNER -/(- o f PERMIT DATE: /D-/7-4S COMPLIANCE DATE: Separation Distance Between the: Feet Adjusted Groundwater Table and Bottom of Leaching Facility Maximum Private Water Supply Well and Leaching Facility If any wells exist Feet within 200 feet of leaching facility) on site of Facility(If any wetlands exist Feet Edge of Wetland and Leaching within 300 feet of leaching facility) Furnished by fl No. Fee '-,THE COMMONWEALTH OF MASSACHU ETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTAB ., MASSACHUSETTS Application for Di.5po�aL*patent Con truction Permit Application for a Permit to Construct(4j)4tepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 330 Cor"va" /? Owner's Name,Address and Tel.No. 4/2 8 !2 S"/4 Assessor's Map/Parcel OP,g 03� , D alf n ons' mil./ Installer's Name,Addressj and Tel.No. y`f 0 36/9 Designer's Name,Address and Tel.No. Jas�/�h lte /,JJ�rrO$ Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 4 t Design Flow 8 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 Smoal Nature of Repairs or Alterations(Answer when applicable) F_ i5��ia �'c�s 7n�a�S Date last inspected: Fr 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 this Board of Health. Signed Date_10—/S-OI8 < Application Approved by ,-1 Date Application Disapprovedifor the following reasons i - Permit No. Date Issued -/Id A THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-s'te Sewage Disposal System Constructed((4-Repaired ( )Upgraded( ) Abandoned( )by ,�hy cf /,� at ,��ordiT �� r%;4A4SrOHs h.,.//s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No:�- fCZ dated Zd Installer Jo.S efJ�01'� aAe,-,V t Designer 45 r eb 2- �pr+r0 5 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date I r-) - ) t_, r� Inspector No.' /�G/ '" j�...^----°_-------------------'Fee [� THE COMMONWEALTH OF MASSACHUSETTS �50 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mitpo5al bp!5teut (Con0truction Permit Permission is hereby granted to Construct(v)'Repair( )Upgr de( )Abandon( ) System located at 33D 601- l it f2� l�llar"s'fOt9.3 L?9i��C 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 it. Date: /!a Approved by 1019197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSA►.L WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 1, as ��„�,dS ,hereby certify that the application for disposal works construction pem-pit signed by me dated /D-- /S= �?g , concerning the property located at 33 0 meets all of the following criteria:.- 4--There are no wetlands located within too feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed 41 There are no variances requested or needed. /f the proposed)*aching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will ngl be located less than fourteen(14)feet above the maximum adjusted ro o Y P P g groundwater table elevation. Please complete ithe following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) I __ B)Observed Groundwater Table Elevation(according to Health Division well map) 30 SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch pllml.of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.cert 5 140 Y=� y u d 1S0° O