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Home My WebLink About0119 PIN OAKS DRIVE - Health 141 PIN ;OAKS,LN.'',%ARNSTABLE A = 280 036 f n c O ry a n f` �LC9<-`� Fee ¢ No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for rie;pogar *raemc Construction Permit � Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) O Complete System F ndividual Components 121 Locatrrilarcel or Lot No ;/J p� J�,, ��/ Owner's Name Address and Te.No. Asses 1 ,C'� //��rs��le 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 1 2-0 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow r7 7e� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank C�00 S _* Type of S.A.S. loll' WX Z - -Description of Soil 6 111,4 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 his Bo o ealth. Signed Date Application Approved b Date� d Application Disapproved for the following reasons Permit No. Date Issued � �� , TOWN OF BARNSTABLE LOCATION [�� Glt/CS l�l, SEWAGE # Z�z 3� VILLAGE / la15 f�O`f' ASSESSOR'S MAP & LOT z�� I INSTALLER'S NAME&PHONE NO. �/�✓ � j �ns 7��'�3�� SEPTIC TANK CAPACITY l��® LEACHING FACILITY: (type) (size) r�i Nd NO. OF BEDROOMS - BUILDER OR OWNER } PERMITDATE: 5 Z 7�O COMPLIANCE DATE: i 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 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 _. _... ................. I eo �_ �C./ w C� e � �./ ! Fee ' No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y PUBLIC HEALTH DIVISION =TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Mi$pogal *p.5tem Construction Permit Application for a Permit to Construct( )Repair(�')Upgrade( )Abandon( ) El Complete System Meindividual Components Location Add's or Lot No. Owner's Name Address and Tel/.No. Assessor's�Maparcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7,7/- Type of Building: f" Dwelling No.of Bedrooms � �, Lot Size sq.ft. Garbage Grinder Other Type of Building C5l e* C No. of Persons Showers( ) Cafeteria( ) Other Fixtures ' Design Flow Il el gallons per day. Calculated daily flow 7 7� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank pOD X Type of S.A.S. ��X��/' Z Description of Soil 6 1114 1111, of . Nature of Repairs or Alterations(Answer when applicable) I-jAle Date last inspected: Agreement: f 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 his Bo ;d qf�flealth. Signed Date Application Approved b Date Application Disapproved for the following reasons Permit No. Or le- DateI"ssued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ---I BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT FY, that the On-site Sewage Disposal System Constructed( )Repaired(Upgraded( ) Abandoned( )b G'/ a�o has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Per;i(NOYP'` dated Installer A Designer a; t The issuance of this pe h�l n• b construed as a guarantee that the sy tem will function as desgned��. Date l ,� Inspector �11f//Al n %!/ No.�� j''f/ ' V 7" W ✓ Fee '-" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopoml *p0tern/Conoruction Permit r Permission is hereby ted to,Cons ct� f)Repair(�')Upgrade( )Abandon( ) " System located at � < 9j s to le- 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 byecompleted within three years of the date of thio4mit. Date: G Approved �f - f / LS99 NOTICE: This Form Is To Betsed For the Repair Of Failed septictic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL 'WORKS CONSTRUMON PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the aDolication for disaosal works construction permit sis med by me dated .5`l a4ao conce—mini the property located at /l q ,dill A/-&A meats all of the followins criteria: :he cued Yszem is ccnne;e,!o a:esdendai dweiling oniv. iae:e are no cotnmercai )r..ms-:ness / uses associated with the dwelling. ne soil is ciassine as C ASS :and:he ye:_oiaucn_ate is less than or�ctmi :c : =utes ter me L ae=are no wetlands-within 'Co ter:cf to ororeser etc s:rent 6/ ae:.are no arvate wei?s within :_0 fed:of he zromsed_eatic system b' :sere is no inemse in low andicr:han,e�n ie?romser t ?ter e are no variances =ues,,ed cr needed. The bottom of the proposed leaching facility will not be located less than dve tee:above-he ma�dmum adjusted gtoundwate: able-!e=on. Adjust the;oundwater able icing the?:=p to method when applicable] Xfhe S.:J.S.will be located with_50 fee:of any vegetated-wetlands. the bottem of the xcrosed leaching facility will not be located less than fourteen(14)Ieet above the ma::=um adiuser groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) �� B) G.W.Elevation �� y the MAX High G.W.Adjustment. = e DUTERENCE BETWEEN A and B 2 ` . 0 SIGNED : DATE: (Sketch Proposed plan of system on bad]. b F , I All pecK Wad/' TOWN OF BARNSTABLE C° LOCATION Ai ealCs SEWAGE # AO&*3141 VILLAGE -&--II,5-W- �J /ASSESSOR'S MAP & LOT 79V d INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Yigaa LEACHING FACILITY: ( pe) (size) to NO. OF BEDROOMS A BUILDER OR OWNER PERMITDATE: S�Z 7�O 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 of leaching facility) Feet Furnished by dg—i � r i q-) 3 Q 4 -3 9 —,f Q— a ��ly .��o