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Y { � Y -y!S .J•l ' ..i. t � l r No. Fee BOARD OF HEALTH TOWN OF BARNSTABLE Zlppricattou jfor Yell Cougtructtou permit Application is hereby made for a permit to Construct Alter( ), or Repair( ) an individual well at: 3$5 'q 4 &0w")� V` , S Location-Address Assessors Map and Parcel c Owner Address Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well 'A" S(ft ?� (— Capacity_to i cw),-, Purpose of Well L Agreement: The undersigned agrees to install the afore described 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 Certificate of Compliance has been issued by the Board of Health. Signed -i 12:d 15 Pate Application Approved By 2 9�/-5 Date Application Disapproved for the following reasons: Date Permit No. Issued Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the in'A)dividual well Constructed(), Altered( ), or Repaired( ) Installer at 3 0ttr� has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private We 1 Protection Regulation as described in the application for Well Construction Permit No.i�l5 —61 2 Dated -716a1is THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector S i No. 1 Q Fee BOARD`OF HEALTH TOWN OF BARNSTABLE 2pprication jfor Vetl Cow6tructiou Permit Application is hereby made for a permit to Construct(�, Alter( ), or Repair( ) an individual well at: MS Location-Address Assessors Map and Parcel IN ` Owner -r Address Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well ��1 S( �� Capacity (0 omy Purpose of Well L Agreement: The undersigned agrees to install the afore described 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 Cert' Cate of Compliance has been issued by the Board of Health. Signed Z S ate Application Approved By 12 --)1— Date Application Disapproved for the following reasons: Date Permit No. l,.�c` 7 Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed U Altered( ), or Repaired( ) by Nit I n(_ `n ' 1` Installer at �A5 V Vt 1101�J .�_CT' _ �k" L 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 Nq 0 J 7 Dated -7 4�0 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector - BOARD OF HEALTH TOWN OF BARNSTABLE Yell Cou5tructiou Permit No. ' .(� —� / Fee Permission is hereby granted to Installer (J to Construct(J`, Alter( ), or Repair( an individual well at: I' ` A' No. �rj Vr 1 1uW + i�� • a��� Q Street ) as shown on the application for a Well Construction Permit No. — l , D' ted / r,D Date /T/ �n Approved By ®/ TOWN OF BARNSTABLE A LOCATION 3�� rl���T SEWAGE # VILLAGE dcyny,5tahle /ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. � Gy7J SEPTIC TANK CAPACITY 1000 ' LEACHING FACILITY: (type) c-Qj CJaa4a9n (size) Z. K 3 5 NO.OF BEDROOMS B BUILDER OR� H4764 1. PERMITDATE: ©/`�l�I COMPLIANCE DATE: Separation Distance Between the: r ` 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 q� -78.3 V3 �3 ! �--- No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplica.tion for Migpozaf *p5tem Construction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System L+SIndividual Components Location Address or Lot No. Owner's Name, ddress and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(100 Other Type of Building 5l CC'No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow Y�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /5--00 ��` y'I`/�� Type of S.A.S. J—J—p® e,11-5-1 Qiw �� Description of Soil Nature of Repairs or Alterations(Answer when applicable) �1 ��le l/-- 70�0 GIiQ'Ci � 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 is B of alt �y Signed Date Application Approved by 0 —Date Application Disapproved for the following reasons 40 Permit No. 3 Date Issued /o—'r—9 No. � ks �t� Fee .� � k THE COMMGNWEAL'TH OF MASSACHUSETTS Entered in computer _ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS . Zippftcatton for,;Dt.5po9;ar 6pgtem Congtructton Permit Application for a Permit to Construct(,°)Repair(4;K)Upgrade( )Abandon( ) El Complete System LJ"Individual Components '➢ �>i ( K t Location Address or Lot No. � /�i�! '/� �r.r- Owner's Name, ddress and Tel.No. Assessor's Map/ParcelIle Installer's Installer's Name,Address;and Tel.No.. ' ¢ Designdr's Name,Address and Tel.No. d© f 7 7/- 31�' Type of Building: Q Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building 5 , o. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow Y�� gallons Plan Date Number of sheets Revision Date Title Size of Septic Tank /�7�D© .�`��I"/tip Type of S.A.S. 7,y c Zw Z_ Description of Soil X y4 X 2 Nature of Repairs or Alterations(Answer when applicable) 72P 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 t is B of alth. _ Signed Date. Application Approved by Date �Q Application Disapproved for the following reasons Permit No. S Date Issued /0— S-9 7 ---------------------------------z------ THE COMMONWEALTH OF MASSACHUSETTS /3 3 j BARNSTABLE, MASSACHUSETTS Certificate of Compliatice THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(r<Upgraded( ) Abandoned( )by at C�ST (.�• I�Cy/i75 O 4E has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. — dated Installer Designer — The issuance of this permit§W, not c s�trued as a guarantee that the Rfxvill,function as des wed.,-" Date . � �' Inspec r � f ------------------------------z--------- No. 3 �O/3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Ot!5po.5ar *pgtem� ongtructton Permit Permission is hereby granted to Construct( ) epair( Upgrade( )Abandon( )° System located at l //�4e�, s r 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 t. Date: is�9�' Approved by r r +` u6/ 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 DESIGNED PLANS) L hiAl r Y�/^�� hereby certify that the application for disposal works construction permit signed by me.dated /Z��Q� , concerning the property located at �'��l%��Ql.�s7` /� �Q�"e,5 eg4-le meets all of the following criteria: +/ The failed system is connected to a residential dwelling only. There are no commercial or business es associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. /There are no wetlands within 100 feet of the proposed septic system /There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed t✓ There are no variances requested or needed. ✓ The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor lif ethod when applicable] the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 7, B) G.W.Elevation 'Z5--+the MAX High G.W. Adjustment Z 13= Z T 3 DIFFERENCE BETWEEN A and B J 6 SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder:cat a o� G yti�Ddk�l AA I • �o LL ...777 �V \J C �Iv TOWN OF BARNSTABLE p LOCATION ✓�� r�sT SEWAGE # VILLAGE �� � /'k5�`t�'�lL� /ASSESSOR'S MAP & LOT INSTALLER'S NAME &PHONE NO. vfl�:�`1 C®�✓S�` 77/-�/j�� SEPTIC TANK CAPACITY /cam LEACHING FACII.rI'Y: (type) Zr,—,,�gc; l dnQA,ae!q (size) 171.5 K A 5 NO. OF BEDROOMS BUILDER OR�WNE t/llr�y PERMIT DATE: r©l 5 l I COMPLIANCE DATE: 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 r�o-ffl leaching,facility) Feet Furnished by O Op S"q ��