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HomeMy WebLinkAbout0114 CHILDS STREET - Health 114 CHILDS ST. CENTERVILLE A = 249 008, Oxfforde NO. 1521/3 ORA 10% .."'.+... . ..-.,,,..�r.Y�w:~�"":.�,.�.:Y.}`<��"!,, r. /��1 ..� ---t!-'• •r-� r. Via.. f"�; '.r-.�'.!+, r1 _ �...—..,s! 9-T j No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ys PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Diopont *pztem Con.5truction i3ermit Application for a Permit to Construct( )Repair( )Upgrade( d)Abandon( ) /Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. /(/J7 /v v Designer's Name,Address and Tel.No. / krl'�T4plll Type of Building:Dwelling No.of Bedrooms J> Lot Size sq.ft. Garbage Grinder(/019 Other Type of Building !°i 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 OgeW Type of S.A.S. ®/ / Description of Soil sze 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 by is Boar4,qf Hea h. / Signed Date �1 Application Approved by - r Date ��' e 2erwt Application Disapproved for the following reasons Permit No. Date Date Issued No. At"i4�r✓ j Fee �P/, T ` Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS . s ' PUB.LIC,HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZMplication for Mioo dl *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( ✓)Abandon( ) le/complete System ❑Individual Components Location Address or Lot No. C , 5 , Owner's Name,Address and Tel.No. Assessor's Map/Parcel ill?//e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. fora ©� 1 Co 7 - �9e Type of Building: } Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(,�_o Other Type of Building of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank '74 Type of S.A.S. Description of Soil �� 'JrO� ll�/C ©!w~5 Nature of Repairs or Alterations(Answer when applicable) Y �s 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 Board f Health. Signed Date Application Approved by C/r Date ��' �'F 2'✓r d f Application Disapproved for the following reasons l Permit No. Date Issued ----------------------------------------- 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 at / has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Perm s 41 dated 0r'"' �?— �fio l Installer Designer The issuance ot this J ermit shall not be construed as a guarantee that the sys 11 fu desig e� Date �y Inspector No. �tJG� � --- --- J / '��Fee---- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ;Digpogar bpgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )U grade( Abandon( ) System located at /�y C!!/�� 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 thi 7 't. / Date: Approved —•+ �_,�.f �(/" `a/ ��i/ NOTICE: This Form Is To_Be-Used For the Repair Of Failed Se -tic Systems. Only. - CERTIFICATION OF SKEFTCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) here" y certify that the application for disposal works construction permit sued by me dated concerning use property located:at /l y�id�f��Cs C2/l ., /!/ rn =s aj-of the following criteria:. IIe ra11ed is conne:.ed to'.a resiL:endal'1we'i'in a n'. v 0—!Y. _IIe:a are IIO ci)tIL"Iler%.2l Or jVtII��...5 Uses?_SsCciated with the t:w icing 1 IIe S011.is cuss--' ed as aAS 1 c..nQ�.� a 'fie P .^.e.^...7iaII6il�L_ 1S :�.� •n,Tl Jr-�liFti :D.� 1nSnL1I...5 ce: _nC:l: ere are no we•dmds .viihLm Ioo of 1Zc:,tacos":rout stem �i ne-c are no nr:�ate;�ei� -;• - - .. s���.t__0 ___of the prcnosed septic syszz..m. is no in==e ,n flow and/or. Y ne:a ire no Var.anc=S.r=usLed or n==,d The bottom.of the proposed icacaing aclity =31 not oe located tea 1es- fiveabove the nzmim=adj=--i,—;=darate:mbie elevation. (A dj=,the --mund-Aate:.tab e.using the:=ptor ethod when applicabicl, if-the S.a S. will be located with._5o feet of a,-tv ves_ated welands. the bottom of the proposed leaching facility will not oe Iocated less than fourteen(14) lee:above the ttta.-dmum ad=e gioundviater table elevation, Ple:+se complete the foilowinb A) To of Ground Surface 3I^ation tsit g G p ( ,CIS information) 3) G.-W.Elevation -the IviA,`{ high G.W.AdjL,=ent. ��Z _ DIT-FERENC BE PWBrz A and 3 j SIGNED DATE: (Sketch proposed plan.of syst.ent on back]. � g � � � � . . a, � �1� 0 ; © a ��hr , � /�X � � �l G�2al�2f�Cj"�' z- �� .� � - TOWN OF BARNSTABLE LOCATION . C /I I v5,7L. SEWAGE # 700/` ,3,S`V VILLAGE ew lerlll kl� ASSESSOR'S MAP & LOT Z Vf-4V INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY La ., / LEACHING FACILITY: (type) SODG, e Cu<< w4� Q� (size) /o?.S�af� NO.OF BEDROOMS BUILDER 6F<OW ���G O/12,6!7 PERMIT.DATE:^ L� �+ �r�s/COMPLIANCE DATE: `"`�-'ae-,, .Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J�f Feet Private Water Supply Well and Leaching Facility (If any wells exist J/ on site or within 200 feet of leaching facility) w Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Q« 'b i �S 3� 3s