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Home My WebLink About0145 WAKEBY ROAD - Health o PAR'0 145 AKE0 MAP 43 / rS 1 0 n r' Y fy 1 7 • �r i L t l No. Fee �No THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migpozar *r5tem Conztruction Permit Application for a Permit to Construct( )Repair( )Upgrade(Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. //, A�j�/q�� Owner''s Nraame,/Addrress and TTL No. Assessor's Map/Parcel �`'�l�J`F v�✓ /" / mil �✓r/� //J Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. AD1-%O� � &O/9211-7 7 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 `� � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ILI)XW X?_ Nature of Repairs or Alterations(Answer when applicable)/ 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 issue y this B d of Heal , Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No. Fee \✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS I 01oorication for 33ig000l *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(/Abandon( ) []Complete System Ef Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel, �� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Bon o GdI�'l C0e_07`` Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building ��S�i/ OH/P No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title i Size of Septic Tank / S`G�� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Bp4rd of Healt //3; , Signed Date 7 Application Approved by Date Application Disapproved for the fol owing reasons i Permit No._ Date Issued ———— —— — —— ————————---—————————--- THE COMMONWEALTH OF MASSACHUSETTS 04/3—Da .`, BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(✓ Abandoned( )by /117241,o J"/ eOAE2 : at !'� ,�'�Q/.S s i.�S ha*ated constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No . Installer AnI f1-ilG'411 CD!%S7` Designer The issuance of this permit shal�l__nTooe construed as a guarantee that the system will ctionfas esigned. .l Date f Inspector � � v — -—L————————-————— -——— -- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migooar *pztem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( Abandon( ) System located at /lit Yd /0; 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: Construe ti mus a completed within three years of the date of this it. C Date: Approved by , ✓ v C - I TOWN OF BARNSTABLE LOCATION �� Q ��y yam' SEWAGE# ? 7—j�� VILLAGE-A119R5�75/eJ11-f ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. Dl6j�D/1�5T 771-Z3A9 SEPTIC TANK CAPACITY �S_d�/'6g,C- LEACHING FACILITY: (type) (size) /O X yo'/'c- NO.OF BEDROOMS q BUILDER 09"b�_ PERMITDATE: 7'�$-'�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facilityf 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 a S TOWN OF BARNSTABLE fi y sEwACE # LOCATION �y '" ASSESSOR'S MAP &LOT VII,LAGEv'�5/f� T 77/-93� INSTALLER'S NAME&PHONE NO. BGr � j�D/l`S 1 dd SEPTIC TANK CAPACITY ,(' / /o X yo ' LEACHING FACILITY: (type) ' ' To4 6 (size) NO.OF BEDROOMS BUILDER O O PERMIT DATE: COMPLIANCE DATE: - �! Separation Distance Between the: ;Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility private Water Supply Well and Leaching Facility (If any wells exist "ell# :Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist � feet within 300 feet of leaching facility) Furnished by Ae pi 4 lob � cps vw 0 0 OT i NIC M. E. Thus Form Is;To a Used For the RepairKOfFafled Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAi WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLA_n I, AD/rV^ ,��/ C� hereby certify that the application for disposal works construction permit signed by me dated 712k 7 concerning the property located at / ��'4C� /�l'D/sfd�5�li�6meets ail of the foilowina criteria: /� ere are no within m�00 fee,of.h..proposed 5epnc system �►' 1hee are no private weils—/thin i 50 eet or-he proposed septic 3vstem Xhe'obs-rved zoundwater moie is i-feet or_greater.oeiow the pottom or hz :eacnirv_ aC_ir - ere s no increase n Liow and/or caanQe in ase orocoseci �- ?SIGNED : DATE: 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 shoMdlbe submitted]. Re<s-'3' - :tea.�•, .1' - .