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Home My WebLink About0028 ASHLEY DRIVE - Health r 28 ASHLEY DRIVE, CENTERVILLE //// QicCrCtEp UPC 12543 � c No. 53LOR co HASTINGS, MN TOWN OF BARNSTABLE LOCATION _ `> SEWAGE # - 1 VII.LAGE �a� PQe ASSESSOR'S MAP & LOT /i7I- d�(o INSTALLER'S NAME&PHONE NO. /,9I d CX)Oe- Se,d 11 L 7 7Sr-66�Eq SEPTIC TANK CAPACITY /S O U LEACHING FACILITY: (type) %irJ 7C/Z e�/Pi9'r6, _.(size) -_ T NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: -10. -9`E COMPLIANCE DATE:- I 1 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 i . . I�C L--J 1. 13 0 14 3� /�3 No. / t 7 Lb _ Fee ks0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migpogal *p5tem Con.5truction i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. CASY1'Vn 0 b�k V t Owner's Name,Address and Tel.No. Assessor's Map/Par el C e V l+_CX V ` "L �A Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. R 2U vo(,gbK 12U1��c `s 02(P o I G� �- Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 U gallons per day. Calculated daily flow Z4 cl gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1`Jfi1 VIA t U (3 Q Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)_In--J L—A It '1' h I U le1A 120 ln-P MZY6 n,P Q-- 3 b54 W 1 i 1 ) 1/1-r on ILA !t IA.Vt QU.VV1.Q fl' 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 Environme tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issu Signe t Date -3 46-Z Application Approved by Date .-b —1 D Application Disapproved for foll ing reasons Permit No. Date Issued No.—?-9 =I�i Fee C� f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ 1i' Yes, PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS 3pprication for �Digotar *paem Construction Vertu Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. l j l,� t v t Owner's Name,Address and Tel.No. Assessor's Map/Parcel C'e nk'� V, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �20 LK r20► A 02coo ( �0 ) i Type of Building: Dwelling No. of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 tJ gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1-5b V1G1 0 U Type of S.A.S. l 6 d Description of Soil Nature of Repairs or Alterations(Answer when applicable) Gl QC1 In V1 CAX_VVl1 6-L4'0 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 Environme tali Code and not to place the system in operation until a Certifi- cate of Compliance has been issue oar 'It . SignecT Date 3 40 Application Approved by Date Application Disapproved fort foll ing reasons 7 Permit No. Date Issued ———————————————————————————————=�-- ———— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS .4 (Certificate of (compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired (Upgraded( ) Abandoned( )by CYO'az I/ at _ C' has been constructed in accordance �. with the provisions of Ti e 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall no_t be construed as a guarantee that the system will function as designed. Date I 1 5i - Cyst Inspector --C-- No. I& Fee 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Mi5potar *pgtem Conftruction Vermit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at r) bh Din \/e C P V\l c V V i 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 permit. Date: Approved by r h 1ON197 • s To Be Used For the Repair.Of Failed NOTICE: This Form I Septic Systems Only. N OF SKETCH AND APPLICATION FOR A CERTIFICATIO DISPO SAL WORKS CONSTRUCTION PERMIT (WITHOUT , ENGINEERED PLANS) ereby certify that the application for disposal works i 1' - �- concerning the construction permit signed by me dated — 1 v meets all of the property located at following criteria: �/• There are no wetlands located within 100 feet of the proposed leaching facility vote wells within 1 So feet of the proposed septic system ; V• There an no private v. There is no Increase in now and/or change in use proposed ' / or needed. ` v There are no variencd requested "• if the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the ed leaching facility will sac be located less than fourteen(14)feet above the maximum adjusted proposed oundwater table elevation. i Please complete the following: according to the Engineering Division O.I.S.map) A)Top of Ground Elevation($)Observed � Groundwater Table Elevation(according to Health Division well map) ` DATE: F 7 sIONED i , LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER I [Attach sketch plat Grew proposed eyoon.Also Itthe Ileensed Installer pognse� eMlfled plot plan, this plan should be submitted). I ' is er kft Imam an C i v- l� , - G