HomeMy WebLinkAbout0389 BUCKSKIN PATH - Health 389 BUCKSKIN PATH, CENTERVILLE
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NoP22-1 3�LOR
HASTINGS,MN
No. 7 71 & Fee��
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Migpooal *potem Con.5truction i3ermit
Application for a Permit to Construct( )Repair(V)upgrade( )Abandon( ) LJ Complete System El Individual Components
Location Address or Lot No. �p ` Owner' Name,Address and Tel.No.
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Assessor's Map/Parcey"e-y ll� �1� ���/
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
771-?3A '
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(✓f
Other Type of Building �Piz'C�No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow '2�rTo gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �r���®Q� Type of S.A.S.
Description of Soil /l ,eo QX Z
r
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 this B d f Health.
Signed Date
Application Approved by Date /,Q
Application Disapproved fort following reasons
Permit No. / T ^ 6 ,37 Date Issued
�v• .., ` . ,try•-*-•� _ A! '. �y`
No. 9�p N
(1 � 3-7 Fee V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -,TOWN OF BARNSTABLES MASSACHUSETTS
0[pprication for 33i_4pogal *p5tem Construction Permit
Application for a Permit to Construct( )Repair(i/)Upgrade( )Abandon( ) U Complete System ❑Individual Components
Location Address or Lot No. 3 8-? B4cl_J!. llfA+ Owner' Name,Address and Tel.No.
Assessor's Ma /Farce
Installer's Name,Address,anShTel.No p,r®�5 Designer's Name,Address and Tel.No.
7 7/l-c�399
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(4D
Other Type of Building d-5 JC =X1n- No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /4,0,0 gallons per day. Calculated daily flow �r�� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /J ®®9P Type of S.A.S. el-5
Description of Soil /j
Nature of Repairs or Alterations(Answer when applicable) r/ �
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 thi B d f Health. /
Signed `��� Date
Application Approved by �e.r,.�n 1� %. Date /D
Application Disapproved for th following reasons
Permit No. 3 Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(tertificate of (tompfiance
THIS IS TO C]51ZTIFY, that the On-site S wage Disposal System Constructed( )Repaired ('� )Upgraded'( )
Abandoned( )by D� /� o��,r G0119 /
at , f 3 e1e s 1jV 4�` has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No YI6'eo3 7 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will unction as designed.
Date Q " j 113 Inspector
--------------------------^/--)------------
No. �e� " &37 `/ �//�, Fee 15C�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migoal 6pgtem ,Construction Permit
Permission is hereby granted to C nstruct( )Repair( Upgrade( )Abandon( )
System located at g 9 �UG/C S/r%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: 6 f - Approved by�,�
tome
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)
1, Aolerr�zypf-712�, 6ereby certify that the application for disposal works
construction permit signed by me dated ���!�� , concerning the
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property located at ®4 4:-7! �� �1 meets all of the
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
F/ 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.
[f the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will p4I be located less than fourteen (14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Elevation(according to Health Division well map) 3�
SIGNED: DATE:
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].
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' TOWN OF BARNSTABLE /
LOCATION 3$� f6aClC-�lrl A7.7- I/ SEWAGE # 9�b 37
VILLAGE ce e zifn1l1le-- ASSESSOR'S MAP & LOT/ /
INSTALLER'S NAME&PHONE NO. AY�,09 e445Z 7 X/-�j��
SEPTIC TANK CAPACrff /fT Gc.G
LEACHING FACMrrY: (size)%d
NO.OF BEDROOMS 3
BUILDER O O
PERMIT DATE: —� �� COMPLIANCE DATE:_ [Ll_ k
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) // `l Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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TOWN OF BA.RNSTABLE
LOCATION ` gaCk,g J irl �� SEWAGE # 9�4137
VILLAGE Ce etl A—T I/l'ZZe_ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type w� y (size) %d ,:?-0 "
NO.OF BEDROOMS 3
BUILDER O C
R O �1�t�L
PERMTTDATE: �—� `� COMPLIANCE DATE: ir; 13-9 Ff
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r 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
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