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Home My WebLink About0096 AUTUMN DRIVE - Health 96 AUTUMN DRIVE, CENTERVILLE A= y I �J�aEcvcifo�oy J 11t8(lLG O _i UPC 12543 No. 53LOR o�PoS7•coNSJ�� HASTINGS, MN No. Fee $5 0 . 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Migoml *pgtem Construction Permit Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 96 Autumn Drive Owner's Name,Address and Tel.No. 4 2 0—21 3 0 Assessor'sMap/Parcel Centerville, MA Jane Davern 96 Autumn Dr Centerville, MA 0 632 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Sry PO Box 1089, Centerville, MA 026 12 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching con i i na of D-Box, and three H-20 stonepacked infiltrators Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this o e of Health. Signed kC4 Dates Application Approved by do 41.1 Date Application Disapproved for the following reasons Permit No. Date Issued �� TOWN OF BARNSTABLE �. LOCATION 2 4 4 0-d,Wi✓ SEWAGE # �'o�d f VILLAGE �FiU,�p 1!zL , �l�f$ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �!�4 ��o'✓ 7 7!= >76 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) --2 -l4�& (size) op. NO.OF BEDROOMS BUILDER OR OWNER T') Ovuexx PERMTTDATE..4 COMPLIANCE DATE: Separation Distance Be een the: Maximum Adjusted Groundwater Table and 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 � ,�. � G� � �use ,� i � � � ��.� � � r� � Aw ®� x �� , _ No. d >. . Fee $.5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered'in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES'MASSACHUSETTS Yes -prication for �Bigonl *pgtem Con.5truction Permit Application for a Permit to Construct, Repsafr PC%)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 96 Autumn Drive Owner's Name,Address and Tel.No. 4 2 0—21 3 0 Assessor'sMap/Parcel Centerville, MA Jane Davern 96 Autumn Dr Centerville, MA 0 632 Installer's Name,Address,and Tel.No, 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Sry PO Box 1`089, Centerville, MA 026 12 Type of Building: Dwelling No.of Bedrooms r 3 Lot Size sq. ft. Garbage Grinder(nc) Other Type of Building .N6'o ?eiso s Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated.daily flow gallons. Plan Date Number of sheets Revision Date 'Title f* Size of Septic Tank T:ype,of S.A.S.' Description of Soil sand c i t 4 -- Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting Ii of D-Box, and three 11-20f-stondpakhed infiltrators. 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 this Poarpof Health. Signed g Date t, Application Approved by Date Application Disapproved fp'r the following reason I Permit No. 9,ZC7/ *` Date Issued + ——————————-——————— ————————————— 31'; I 'TH C`OMMONW,C 4tTH OF MASSACHUSETTS ��'- / BARNSTABLE, MASSACHUSETTS Davern Certificate of Compliance °. THIS IS TO CERTIFY, that the/On-site Sewage Disposal System Constructed( )Repaired (xx)Upgraded( ) Y Abandoned( , )by at a Corvilie has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. -Z°/ dated Installer W E Robinson Septic ,Sry Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector --------------------------------------- No. Z d I Fee $5 0.0 0 l THE COMMONWEALTH OF. MASSACHUSETTS ; PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Davern M gogar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( X�Upgrade( )Abandon( ) System located at 96 Autumn Drive Centerville, MA Installer: W E R®binson Septic Sry 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:Constructions must be completed within three years of the date of this pe, it Z( Ae Date: 7"�f d Approved by _ i a t 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 ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated 3"3/z- 9 F concerning the property located at 96 Autumn Drive, Centerville, meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * 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. * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any 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 Elevatibn(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED- 1c2— DATE — � f LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). ,r .s i 3b ' �' -��b l� � �" � �6 l �! l�j;v G