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Home My WebLink About1736 MAIN ST./RTE 6A(W.BARN.) - Health 173c=Main St. ., W. Barnstable, A = 197 - 036 TOWN OF BARNSTABLE LOCATION 171 Ald/ SEWAGE # VILLAGE A0116A e ASSESSOR'S MAP & LOT le INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY SOU 0,0L LEACHING FACILITY: (type) 41d (size) it s} 7(02 0 NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: CbMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist i- on site or within 200 feet of leaching facility) JrO Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) We Feet Furnished by .Za ewe a� #3- 33' 100 , No. S Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYfcation for Mi!5paaf *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) L/Complete System ❑Individual Components Location Address or Lot No. 7 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. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building " eNo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ile gallons per day. Calculated daily flow 33!J gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1�00 ----Type of S.A.S. 3 -,O 1,WIA/ZK77S 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 b this o o ealt Signed Date Application Approved b Date v2.2 f Application Disapproved for the following reasons - Permit No. Date Issued -30 No. Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZlppYication for Migoml *pztem Construction Permit Application for a Permit to`Construct( )Repair(✓)Upgrade( )Abandon( ) l complete System ❑Individual Components Location Address or Lot No.t 's Name,Address and Tel. o. 173d OwnerAo f'V' AV/A 040(e ? Assessor's Map/Parcel J<.��/� Installer's Name,Address,an Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder('op Other Type of Building74/ L"er No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1164 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1-15-140 Type of S.A.S. 3 {��llfiY//�tX'l%ZCJ�s Description of Soil Nature of Repairs or Alterations(Answer when applicable) �: f - 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 Bo of ealth. Signed Date Application Approved by Date Application Disapproved for the following reasons 1 Permit No. Date Issued —————————— THE COMMONWEALTH OF MASSACHUSETTS `e5) 3 BARNSTABLE, MASSACHUSETTS ?7 Certificate of (Compliance '/ THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( 4�)Upgraded( ) Abandoned( )by 'eaZ, at f 3Z �I/llyl S2'`, �•s T�i� W, 4y/! �`d� has been constructed in accordan e with the provisions of Title 5 and the for Disposal System Construction Permit No. `7�2 S�'3 dated ��. Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date ! Q Inspector No. ZS -------------------- vd�/ Fee f /�. THE COMMONWEALTH OF MASSACHUSETTS 97- PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Misposaf *p5tem Con9truction Permit Permission is hereby granted o Construct( )Repair( VI Upgrade( Abandon( ) System located at /7,3,A,'/1165l- 17"1¢ 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 ermit. Date: -/4/',? Z " 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 DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS). AerIP`f el , hereby certify that the application for disposal works construction P g permit signed by me dated y!Z/` Q g , concerning the property located at 7�� vT > , � iees all of the following criteria: (There are no wetlands located within :00 fee:of:he proposed leaching `'acility There are no private wells within 140 rest of!he proposed septic syste n 'here is no increase in :low and/or=hange in-ise procosed Anere are no variances requested or needed. If the proposed leaching fa,iity wiil -e ocatee-within :=0 reef of Inv wetlands. :he ooncrn of:he proposed leaching iaciiity wiil '-,e :ocated :ess:han :ourteen t,1-). -eet above .he maximun acius;ec groundwater tabo eievation. Please complete the following: Z, A)Top of Ground Elevation(according-:o the Engineering Division G.I.S. mar)) B Observed Groundwater Tabie Elevation(according to Health Division well map) 2 SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER ed installer osesses a certified plot plan, [Attach a sketch plan of the proposed system.Also if the licensed p this plan should be submitted]. 1 c. P A/ Wit'Z l Ga.ra.9 C- h h fl 3e. Flo-; rs 5-I Ric GA C.�• �arr�s-10.b i i TOWN OF BARNSTABLE LOCATION.' : I Q/� �✓r SEWAGE# 9r%—TiSj t VILLAGE_..W a�'1/I�TA�Ir° ASSESSOR'S MAP &LOTT�`'��b INSTALLER'S:NAME&PHONE NO:_ G'Df�Dlo " / 7 SEPTIC TANG CAPACITY LEACHING:FACILTTY: (type) - (size) i/ 9 NO.OF BEDROOMS BUILDER OR:OWNER PERMTTDATE' COMPLIANCE DATE:_ .� -- f � ��_ • Separation Distance Between the: Mazimum:Adjusted Groundwater Table and 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) ISO Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300'feet of leaching facility) /V Feet Furnished by . S pod 01 „9�if-LSD ot�rd ��r Fee-';—? BOARD OF HEALTH TOWN OF BARNSTABLE Appriration-*rle l Congtruftionpermit plication is hereby made for a permit toRc2pstri4ct ( ), Alter ( ), o Re air ( )an individual Well at: Locatio Address &ssesso�rsMap and ParcelOwner ---- -_-----!_✓_ -- Installer Driller Address T e of Building Dwelling--------------------------------------------------------------- Other - Type of Building No. of Persons------------------—-------_---------------- Type of Well--- -- ��----- -- Capacity Purpose of Well------- -- - ---------- Agreement: The undersigned agrees.to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until Certificate of Complia ce has been issued by the Board of Health. Signed_ -- �a date Application Approved B --- date Application Disapproved for the following reasons:------------____________________________—______—___________�___ date Permit No.-- -- "' -mod-'-T? — - - Issued------------------ - -� �— --—_ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed lam), Altered ( ), or Repaired ( ) ----------------- - —-------------------------------------------------------------------------------- y� ,,� l Installer Ile- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation.as described in the application for Well Construction Permit No.49�--`' l>--`-�Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE ---— — --- - --- ----- — -- Inspector-- -- -- - ------- -- ------------ No. -- -_ ____ 1� Fee BOARD OF HEALTH TOWN OF BARNSTABLE p 0pprication-*rMelt Cootruction Permit A,,plication is hereby made for a permit to ��o.struct ( ), Alter ( ), or Repair ( )an individual Well at: ,-�� Icy f t: Cr� _ _ � , tl"� �► ��l�1,�.._�_ _ __ __ __ _ ' Location — Address _—� — Assessors Map and Parcel -- — w Owner t Addfe Vnstallerf Driller Address Type of Building } Dwelling---------------------------------------------------------------- Other - Type of Building-----____ No. of Persons----______�_______—_ _ Type of Well----- / _ �'_ - ------------- Capacity— _----—- Purpose of Well------- � - F Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town`of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until Certificate of Compliance has been issued by the Board of Health. --Signed date l- r lJ Application Approved B -- —�*.= — � �f -- date Application Disapproved for the following reasons:-------------------------_—_______--_ —_ --- - --- ------------------------------------------- -- ---- —_— fj , date Permit No.-- --"-` - '� - -- ---— Issued--- - --- �—��- — date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (;i�), Altered ( ), or Repaired ( ) by ----------------------------- —— --— __—-=-------_—--_ - Installer at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.4��Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------------- ------------ Inspector-------------- ---____------------ -_ BOARD OF HEALTH TOWN OF BARNSTABLE Very Con!5tructionpermit �� Fla,- O� No. -------------------- Fee-----------=---- Permission is hereby granted to Construct (ate), Alter ( ), or Repair ( ) an Individual Well at: r No. -— -� _� _' s _ s✓— --'` -- - =r�'�'— r °_ /S ! hZI -- - --------------------- Street / as shown on the application for a Well Construction Permit No.------- "- �1 ---` ----- --- Dated Board of Health DATE — ".a'l, �'. ,j'-�-- ------- l ��