HomeMy WebLinkAbout0035 SAMOSET ROAD - Health /v/ - tt
r►s�/l���n s� Alow
TOWN OF BARNSTABLE
LOCATION J,5 Sa.n1 oX 4 Qof SEWAGE# 2!p
i VILLAGE //S ASSESSOR'S MAP&PARCEL f J
INSTALLER'S NAME&PHONE NO. ,� yj`g/ t ��( ,� �-60
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
OWNER 0r.lih
PERMIT DATE: 3 (O COMPLIANCE DATE: �a
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
8
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pj 3�ifAr' o� i^ 'uF� I>"$fix
No. G 2- b 7 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: (/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[pphLation for MispoBal *pstrm ConstCUttion i3ffmit
Application for aPermit to Construct( ) Repair(011"Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location,A�ap
ess or Lot No. S J _A rn<o$E"7 j� , Owner's Name,Address,and Tel.No.
AJseessor4( /Parcel ��� fG) K04 T HY
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
R�6�dD �00�4�Ydi
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(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) RQ/ra O 1 r 6 Q
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 Board of Health.
Signed- Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �0�'�'—' Date Issued 3—(c) �—
-
No. b Fee
THE COMMONWEALTROF MASSACHUSETTS Entered in computer:
f \ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Misposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair(1r Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location,Address or Lot No. 3 5- Sp;rn4$e"7° JZ D . Owner's Name,Address,and Tel.No.
' + l�
Assessor's;ap/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms (V Lot Size F }sq.ft. Garbage Grinder
Other Type of Building No.of Persons i Showers( ) Cafeteria( )
Other Fixtures ) y A
Design Flow(min.required) A/ / gpd Design flow provided gpd
r
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) {5atn00 Ls i r C r b oK
ft
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 Board of Health.
Y�
Sim /�.i�✓%.�•�G--� Date .S' l U ' 2
Application Approved by _Q 'A Date � �(Cj ''� 2•
Application Disapproved by Date
for the following reasons
Permit No. U b 7 Date Issued 3 'f d - 2
µ,
---------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance /
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(+' ) Upgraded( )
Abandoned( )by REAP% RQI�- It k
at _� SArc S Z,7 r x . fa 09 iu/ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.% dated 3
Installer .r,D y ko o r FI Designer FA
#bedrooms /V Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system will•fimc.tion.as designed.
Date a/.%L)1. c Inspector
--� ---•
No. g .----•=r-.---__-------------•----_--;�__ ._,..-- _.,.---•-----------•--�•--•---•----•---•---•---•---•-•------ Fee
c, b �--
THE COMMONWEALTH OF MASSACHUSETTS
,< PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Mis oral 6pstrm Construction Permit
Permission is hereby granted to Construct( ) Repair(f Upgrade( ) Abandon( )
System located at a r 410_,�if'f P_d�> : M A 4,YTC/r l,� 0 (/J
and as described in the above Application 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 completed within three years of the date of this permit..
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Date � �� Approved by ,