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HomeMy WebLinkAbout1855 MAIN ST./RTE 6A(W.BARN.) - Health 1855 Main St. , Rte. 6A, West Barnstab A= 216-031 C i j f k 2 No. 4210 1/3 BLU (:Of ESSELTE 10% 0 0 o ---_-- __- ------------ BOARD No. --- -- / Fee— OF HEALTH TOWN OF BARNSTABLE ZppYicat ion,forlVell Con5tructionj9ermit Application is he a e for a permit to Cons uct ( Alter ( ), or Repair ( )an individual Well at: Locatio s Address Assessors Map and Parcel Owp— — -- -- --_---- --- — — Address Installer — Driller 3'77 7— Address Type of Build' �/ ! w I ° welling�'. ----- -— —--— — / r P� q� �.A-�!G ��0 7� Other - Type of Building—=-----_---- - No. of Persons-----_______—__--______ Type of Well-eA e.- Capacity Purpose of Well— Agreement: -��------ 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 unti Cer�ifica ance has been issued by the Board of Health. Signed date Application Approved By ------ date Application Disapproved for the following reaso - ------------------— --------------------- date Permit No. — Issued-- --------- — -- --- ---------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by—_ _--_-----_-----------------___-- Installer at--- --_ ---------- ---------- ------- —__--_ has been installed in accordance with the provisions of the Town of Barnstable Boaro of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -!� /��ated---- ----- 7 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----_—— — — Inspector —___-- r^ No.--- --------- Fee-------------------- BOARD OF HEALTH TOWN OF BARNSTABLE ' Appiication,forlVell CongtructionAkrmit Application is hereb a e for a permit to Cons ruct ( Alter ( ), or Repair ( )an individual Well at:- 4 Location a Address Assessors Map and Parcel / Ow r (� Address Installer — Driller 3�y �7/�/— Address Type of Buildmi / ,¢�G 5/yo cf Dwelling ------------------------------------ Other - Type of Building _--_____ No. of Persons-------------------------- Type of Well Capacity-- { -------- Purpose of Well "L��� — -- Agreement"``A 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 a e 'fica {f'C/o p ilit ance has been issued by the Board of Health. r Sign d - __— _ — � date Application Approved By f///j j/f� ---r— Idate x Application Disapproved for the following reaso -------------/-_ ______--_—_______ - - ----- ----------------------------- date Permit No. - --- Issued �- BOARD OF HEALTH 1 ' 1 TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), 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.fj) O Aated---- ----- 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 Ive[C Con ructionpertnit or 0 o ( Fe - -- -�-N . ��Permission is hereby granted � to �� Cons ct ( . ), Alter ( ), or Repair ( ) n Individual Well-at:. 1/� fl _ Street as sho on the a plicat'on for 11 Construction Permit No. Dated - --- ------------------- �'- f -,-- — '— - - --- =------------- ------ 1 6Board of'Health DATE TOWN OF BARNSTABLE LO 0CATION .� ,`\�� c,-in sf 611 SEWAGE # qe�����a VILLAGE�ie, ASSESSOR'S MAP Gz LOTS INSTALLER'S NAME 6s PHONE NO. -x i - SEPTIC TANK CAPACITY LEACHING FACILITY:(type)� !� ,� ��; (size) Ad TI E NO. OF BEDROOMS RIVATE ELL OR PUBLIC WATER/ BUILDER OR OWNER DATE PERMIT ISSUED:_] / /c/i DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ��� Ly No. ✓ l tl'(a id Fee THE COMMONWEALTH OF MASSACHUSETTt PUBLIC HEALTH DIVISION - TOWN OF•BARNSTABLE., MASSACHUSETTS Applicatton for Migoat *potemc Conot action i3ermit Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. /fs. S" ;r''l Cam G /A I rs GVpp� j. Installer's Name,Address,and Tel.No. - S—U I C- Designer's Name,Address and Tel.No. 72 Type of Building: Dwelling No.of Bedrooms Garbage Grinder(/V 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 Description of Soil sr Aj S/ Cr 0 -Gr 5- Nature of Repairs or Alterations(Answer wheq applicable) w./ -1 14 CNE rs t^-c aft' an e I�:I =n, 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 is d by this Bo of ealth. —" _ Signed Date Application Approved by Application Disapproved for the following reasons Permit No. /�' /�G C Date Issued ——————————————————————————————————————— - Q y f✓ No._ - l Fee 3 COMMONWEALTH OF MASSACHUSETT% '" PUBLIC HEALTH DIVISION -TOWN OF,BARNSTABLE., MASSACHUSETTS 0[ppliration for Migozal *pgtem Conetrurtion permit- Application is hereby made for a Permit to Construct( )or Repair)an On-site Sewage Disposal System at: +e1' Location Address or Lot No. Owner's Name,Address and Tel.No. r'►G: Installer's Name,Address,and Tel.No. - S� � Designer's Name,Address and Tel.No. 72 Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow. gallons per day. Calculated daily flow "^-- gallons. x Plan Date Number of sheets Revision Date 1 G Title Description of Soil 5-1e n J `./ 0 [z(s * I 1' � f Nature of Repairs or Alterations(Answer whe ,pplicable)��k��C�Ll �(0..� \ SSA o� 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 is d by this BoArd of 1ealth. Signed Date M1 9 Application Approved by Application Disapproved for the following reasons Permit No. /-s` ��L C Date Issued /a?//a/�— 7 ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS i Certif irate of Comphattre f THIS IS TO CERTIFY,that the On-site Sewag Disposal System installed( )or repaired/replaced on by CG .AS for C3C,S n n, 10 A \_.., S?, has—been cotistructe '� accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.?5-- /�(o G dated /.� E Use of this system is conditioned on compliance with the provisions set forth below: No. /O v Fee 30 `� THE COMMONWEALTH OF MASSACHUSETTS 'i PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migoml *pgtem Cougtrurtioil Permit Permission is hereby granted to to construct( )repair V J an On site Sewage SysteN located at 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. All construction must be completed within two years of the date below. A?r Date: �.2�/2��'- A roved b CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WI'I'11OU'T DESIGNED PLANS) 1, SW `—��V , hereby certify that the application for disposal works construction permit signed by me dated q3 , concerning the property located at_ f�s S S NAG S�' 6 A w. 25, meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: �5f 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 should be submitted]. i7Z� - © ��