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HomeMy WebLinkAbout0389 BUCKSKIN PATH - Health 389 BUCKSKIN PATH, CENTERVILLE A= 191.119 Qlyf// ti 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. eq 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 P g 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]. q:health folder.cent y � C�\v i II S5 E� jUuG.si�i of ? t ' 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 r Z3 a b, 00 g� S' f i 3o, � p",� 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 3 ��10 q0 a� s� •a' P' 3o, .r,�p«�,.• / FY