HomeMy WebLinkAbout0017 VICTORIA STREET - Health (3) 17 1/; c -7 o P a 57t
C.
No. 6 ' Fee �\
THE COMMONWEALTH OF M SSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippliCation for Disposal 6pBtem Construrtion permit
Application for a Permit to Construct( ) Repair N) Upgrade( ) Abandon( ) ❑Complete System individual Components
Location Addressor Lot No. v jC� ;0. �� Owner's Name,Address,and Tel.No.
Assesso�s� D" arcel Ce,� AewviXtQ. Ak', Oao_ual �CWC,4a & 1Za*C� L �_f � e,fJ�`VC
Installer's Name,Address,and Tel.No. '5j-'j 2 IF Designer's Name,Address,and Tel.No.
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Type of Building:
Dwelling No.of Bedrooms /A 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) U
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 a0 ka,
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
` 7-
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No. ��.1,�� 13 Fee �r
THE COMMONWEALTH OF M SSACHUSETTS Entered in computer: kz
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplitatlon for Disposal 6pstemc Construction i3ermit C)
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) El Complete System [Individual Components
r
Locatiotn Address or Lot No. j U tCO�10. cJ� Owner's Name,Address,and Tel.No. ^;
Assesso`�s�Map�arcel Cl'.��er.f�llft MQ o�eaa 1Zic1f�G.�t�C� l` 0:3JI4 C2 Le_C�O'�C
`7t`Csvc�� [J���1„
Installer's Name,Address,and Tel.No. '45b6-1'6 -0b$57 Designer's Name;Address,and Tel.No.
�G �+ti �� 3� WecQ wooed
C.0,�ae ,,
t i l_o AAA 0,
Type of Building:
Dwelling No.of Bedrooms / A Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( ) L
Other Fixtures ;
4
Design Flow(min.required) gpd Design flow provided t41A gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of.Soil
Nature of Repairs orAlterations(Answer when applicable) C>uAko+
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 !yam_ /`! Date 41301 a,
Application Approved by Date
Application Disapproved by r Date G
r
for the following reasons
Permit No. � � ~' f ! Date Issued Ll! 140 1
----------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS�y
Certificate, of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal
�system
Constructed( ) Repaired(J) Upgraded( )
Abandoned( )by `SG �J 1�L� e `tt i lLt.�l3 1 (SOD—
atCX t Q iYSe " (si >A U, a klQ_ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Not fjaa-QY dated
Installer�i1lV\Q�jL� \ Designer
#bedrooms -Y Approved design flow gpd
The issuance of this
j ermit shall not be construed as a guarantee that the system w�ill`function as�designed.
Date ! �/!',cam.. Inspector
No., Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
-Misposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(\J) Upgrade,( ) Abandon( )
System located at
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 hmust be completed within three years of the date of this permit. ��
Date V / .(3/ Approved by � � /,{ '�•t. ,
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