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HomeMy WebLinkAbout0205 BUCKSKIN PATH - Health (2) 205 BUCKSKIN RD. CENTERVILLE A = nn NoP2�„�15, 3LOR 'gsr HASTINOi. YN TOWN OF BARNSTABLE LOCATION �.C�5 L �C,C S /l� SEWAGE # VU-LAGE �(',r/it r�'/� F ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /t?1 n C e SEPTIC TANK CAPACITY %O d y LEACHING FACILITY: (ty ) % ��` ,1� 7e X S (size) NO.OF BEDROOMS BUILDER OR OWNE qq r lfi ! PERMITDATE: , COMPLIANCE DATE: °, I Separation Distance Lween the: r 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 -� . r E.7 76F1 J. a. J No. / �� Z_ _ Fee y�P THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Miqu al *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) D Complete System :Individual Components Location Address or Lot NozjoS 61S in A-,, Py"` Owner's Name,Address and Tel.No. Assessor's Map/Parcel p 1`o 1 vc\L Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A4 ®- ov Type of Building: Dwelling No.of Bedrooms �1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3q�! gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ILOC-- ST n0be Type of S.A.S. t Description of Soil 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 e Environmen ode and not to place the system in operation until a Certifi- cate of Compliance h ecrrlS e y a th. Signed Date % 7 g Application Approved by Date Application Disapproved for the fol wing reasons Permit No. 3 Zi Date Issued L 3 i No. " 4 Fee J� A � THE COMWEALTH OF MASSACHUSETTS Entered in computer: ` PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes Application for -Migaar *p.5tem Cow6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Individual Components, Location Address or Lot No.;;?o S l7t tL �.S L,,a., t+4't`4 Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. ` . + Designer's Name,Address and Tel.No. _•_ Type of Building: Dwelling No.of Bedrooms- 5 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures l.- c Design Flow(} gallons per day. Calculated daily flow' f gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ' 5`f y`t 100 Q `At ,_. Tyne of S.A.S. 0 r �T_�u Description of Soil LAL Nature of Repairs or Alterations(Answer when applicable) ©v3Qc 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 f the Environmen ode and not to place the system in operation until a Certifi- Cate of Compliance ha,been-issu'2`d"b�'ttti a th. Signed \ Date Application Approved by Date' Application Disapproved for the folrowing reasons 1 Permit No. 3 Date Issued 2 3 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded " ) Abandoned( )by t at t1v I t has been constructe in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 r.3 Z dated �1 Installer Designer f The issuance of duert�steal (n�,t be construed as a guarantee that t e•sy ern will func iori as'designed. Date (� �Yl i Inspector /� a ',& y fe to o No. / ---------------- =-------- r3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE= MASSACHUSETTS Mi5po5ai *pgtem Construction Permit Permission is hereby granted to Construct( )Re air( )Upgrade( Abandon( ) System located at [�,.V VC•, A?o 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 3must be completed within three years of the date of this p�� Date: Approved by L 1f `� 1/6/99 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 DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at d ,- —IR" O u'-) 014t( meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business r /uses associated with the dwelling. `/ The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system l� 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. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor r / method when applicable] u If the S.A.S. will be located with 250 feet of any vegetated 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 Surface Elevation(using GIS information) B) G.W.Elevation -7410 +the MAX.High G.W. Adjustment J` - DIFFERENCE BETWEEN A and B 3 SIGNED DATE: ' [Sketch proposed plan of system on back]. q:health folder:cert Ll , TOWN OF BARNSTABLE LOCATION „?4®� !32 G'.C'Sl �// SEWAGE # v VILLAGE r e/le,r d/�,�F ASSESSOR'S MAP & LOTJ-7/-0/7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY XdW y LEACHING FACILITY: (ty ) i tj M,,z, 2U I' fit' ,7 (size) NO.OF BEDROOMS BUILDER OR OWNE PERMIT DATE: 0 1 COMPLIANCE DATE: i Separation Distance etween 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 AGr �Iti 122-L-