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Home My WebLink About0157 SALT ROCK ROAD - Health 157 Salt Rock Road Barnstable A= 316-011 TOWN OF BARNSTABLE LOCATION 1 '` 3&.40t-K-e!xe_A SEWAGE # 76 ^l VILLAGE ASSESSOR'S MAP &LOT 6` INSTALLER'S NAME&PHONE NO. 27 3 c-)(z o SEPTIC TANK CAPACITY. LEACHING FACILITY: (type) . �/t/�Irl � �s (size)'-, NO.OF BEDROOMS 3 L 1 BUILDER OR OWNER C// 2�� 11TaN PERMITDATE: — —16 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom.of Leaching Facility 4k 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) __/"a Feet Furnished by �� l -�-��{- � , �.� �� s z o�-rw��,f/vL � �� ate.,-�.,,ys �Z = � - � o � ,� s � l � � 1 i' � V V/ 3 /� - 0 (1 No. �( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprica.tion for Migogal *pgtem Cottgtrurtion Permit 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 Te.No. I s� 5� n�- � �{� In 1er's Name,Address,and Tel. Designer's Name,Address and Tel.No. L IS- Type of Building: Dwelling No.of Bedrooms _ Garbage Grinder416__> Other Type of Building No. of Persons 2-- Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil o4"Nature of R pairs or Aygrathms(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-Tile,5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by As Board of Ith Signed Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued T 'T' zr — 0 f No. f Feef P THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZIpprication for Migoml *raem Con6truction Permit ' 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 Te.No. 15 S � � 13«AYV In er's Name,Address,and Tel.No: Designer's Name,Address and Tel.No.' 7s �- Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building No.of Persons Z— Showers( ) Cafeteria( ) Other Fixtures Design Flow G gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of R pairs or AUccations(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.T-i le 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by th's B d�rth!A, Signed "^-' =---- Date Application Approved by Application Disapproved for the following reasons �r M J Permit No. � Date Issued `: _M ————— ————.—————— ——--— — �. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance �THI IS TO C- TIFX�hat�}e On-site Sewage Disposal System installe ( or re airA�re laced(v)"on IS 7 by `{'�2 G-.:.� for � as �--� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: -------- - -------------------------- No. l e �/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS *potern Cgg5�t�ru ction Permit Permission is hereby granted to to construct( )repair( an On-sit,/Sewage System 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 combed within two years of the date below. �.�� Date: / ^� � Approved X__.�--- - � - r7 , CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at /r 7 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: G 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]. � Q 1 i y LA y � co r f N C1 _ t O LA • .'. 17 i w - n V c� d � �3 -1 � y Ch rNo � o 1 I' 001 o . 0 lip fl- z . 1 G� 6� i y i! 00 CrI ro a 00 rt 00 a I � Fr� N. 11EU. i N cy pQco rM 4