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Home My WebLink About0008 CHILDS STREET - Health 8 CHILDS ST., CENTERVILLE A=248.014 i —llll 3 UPC 12543 �4 No, 5__OR HASTINGS. MN I No. C � Fee f THE COMIVOFf1WEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for -Mioaar *pztem eonf&uction 3permit Lem i Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. C_ ej ��i 1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 t ( ()� Inst�er ne,Add ss Vel � �]�� t� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms L4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �� '1� gallons per day. Calculated daily flow qL gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank �� C Type of S.A.S. A-1p Description of SoilrIG1 v 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 issu Signed �i Date ` �� § Application Approved by �&4 _ Date Z—a"!bv_ Application Disapproved for the following reasons `' Date Issued p No. 1 Z/ L15 Fee �s THE COM W&TH OF MASSACHUSETTS Entered in computer: �l > w f Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for )k6pogaf *p.5tem Conotruction Permit L6A- 1 4 Application for a Permit to Construct( )Repair(�/)Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No.8 C_ SO �EI'� ) I ^wn-er's Name,Address and Tel.No. i x Assessor's Map/Parcel o� 1 / �.-I Y(7t4 Instane' ame,Address Tel.N . Designer's Name,Address and Tel.No. ��- C40i�; 5 kL -106AO(ei � V s Type of Building: ,, ll� Dwelling No.of Bedrooms `4 Lot Size 'sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow H �A D gallons per day. Calculated daily flow q 61 gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank k!5_(9b S 1 t • Type of S.A.S. 1 `-,C IV 1-:1 &/r-,L, Description of Soil Nature of Repairs or Alterations(Answer when applicable) I OT 5 t T C4 0 4 i `r v\ w 1 �4 t 5TUNS n,>uS`r�1�5;'-r- 1 4" a NAD-a- `. Ue..r-�h Date last inspected: '" y 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 of to place the system in operation until a Certifi- cate of Compliance has been issu d oE-Iea•1•th Signed liter Date Application Approved by Dats/_ Application Disapproved for the following reasons ?' Permit No. �� / Date Issued -- ,- lJ� j ' ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS r . BARNSTABLE, MASSACHUSETTS (tertificate of (Compliance THIS IS TO C RTIFY, that the On-site Sewage Disposal System Co ucte ( ) aired ( ) Upgraded Abandoned( )by �� C-��C &e\P_C( C — :=1b Y -S at SC L-�i S\ C 2 `C t l\ R_ has been constructed in accordance with the provisions of Title 5 and the for 6isposal System Construction Permit No. '-y.- dated Installer Designer The issuance of this permit shall noott be construed as a guarantee that the system will unction as designed. Date - - / Inspector ————————————————————————————————————-—— No. s-' �" T— Fee y"r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS migozai *pztem�TT on�truction Permit Permission is hereby grantedt Construct( )Repair( pgrade Abandon( ) System located at . 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 e •it. Date: Approved by I019197 NOTICE: This Form Is To Be Used For the Repair Of-Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICIT WITHOUT DISPOSAL WORKS CONSTRUCTION PERM ENGINEERED PLANS) I, O , hereby certify that the application for disposal works construction permit signed by me dated / �-/ -�� ,concerning the property located at I S ST— meets all of the following criteria: • There are no wetlands located 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 within 250 feet of any wetlands,the bottom of the proposed leaching facility will nol 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)_ SIGNED: DATE: LICENSED SEPTIC YSTEM 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:cert S �'�\• �$�Y a LOCATION_ G t L TOWN OF BARNSTABLE �U SEWAGE # VILLAGE E T�1_Z\/S La ` ASSESSOR'S MAP& LOT ' t INSTALLER'S NAME&PHONE NO. ,�—Lys- , SEPTIC TANK CAPACITY I CD SST LEACH NG FACII.TTY: (type) NO-OF BEDROOMS (size) BUII.DER OR OWNER PERMITDATE: I 1 . � COMPLIANCE DATE: Separation Distance Between the: —�--- Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility Feet on site or within 200 feet of leaching facility) any wells exist Edge of Wetland and Leaching Facility Feet within 300 feet of leaching facility) (zany wetlands exist Furnished by Feet k i O y A6z' A . 2GVN OF BARNSTABLE � LOCATION �� " � SEWAGE # '�I 9 - Ll VILLAGE. ASSESSOR'S MAP & LOT t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY e <<:% /��j/� �L size ! d�- LEACHING FACILITY: (type) ( �� ) �:3a?</ NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE:_� 1 : _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted'Gr undwater 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 i � VXY XTV, r 83-2,