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HomeMy WebLinkAbout0015 CIRCUIT AVENUE - Health 15 Circuit. Avenue Centerville = 226 - 178 s M E A to No.2-153LOR UPC 12534 smeadmom • Made in USA TOURCPI RED WG VM3YWROC"u jOPG 7 (Q — r Fee No. .THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.,-MASSACHUSETTS Cj CA(')r Zipprtcation for Mt5pood *p!tem onotruction Verm�tt S implication is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. (f1 rL Owner's Name,Address and Tel.No. FI c V Assessor's Map/Parcel C7 of a ` Q Kr Y - t i<c*_ . �PC� Installer's Name,Address,and Tel.No. r"'1�a �� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_ Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �-9 Design Flow '��� gallons per day. Calculated daily flow Y'4 V gallons. Plan Date _ Number of sheets Revision Date Title ,,r Description of Soil Nature of Rep 'rs or Alter ions(Answer when applicable) f C_ 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 Env' onmental Code and not 1 e system in operation until a Certifi- cate of Compliance has bee n Signed Date " `8�Q Application Approved by IzA Date Z C, Application Disapproved for the following reasons Permit No. �� 3 7 /Z Date Issued 4 'PIS (f,// Fee, l ~ THE:COMMONWEALTH OF MASSACHUSETTS 3 I PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIpprication for die;pooar *p!tem ongtruction permit N/�Application is hereby made for a Permit to Construct( )or Repair.( ,�)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. /'S G r�.rr W.p ypnw' I Assessor's Map/ParcelAI IQ Installer's Name,Address,and Tel.No. ' '1© 6p , j Designer's Name,Address and Tel.No. . o G CTT t f Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow < gallons per day. Calculated daily flow D gallons. Plan Date Number of sheets Revision Date Title N_ Description of Soil E_0 _5,4^ ) a F + Nature-of Rep 'rs or Alter ions(Answer when applicable) ST �t L K�c: 0 �w TvizUnS LA.4 Alf 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 Env' onmental Code and not o e system in operation until a Certifi- cate of Compliance has bed y-ts-liar e n Signed Date Application Approved by Date Application Disapproved for the following reasons q o -- Permit No /� �� J �i Date Issued l —————————————� -------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ` « k ' I f ' Certificate of Compliance ss IT CER t the O -site Sewage Disposal Systeminstalled( )or repaired/replaced( �n by e i� �-tJ�x _S Installer G-)kc-`.__ j at e,+r'c c-5T' wwA ✓1~ has been constructed in acc dance with the provisions of Title 5 and the for Disposal System Constructiev.Perini No. 9 2 dated (F Date / Inspect%r`� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANT);E4HAT THE SYS- TEM WILL FUNCTION SATISFACTORY. C ORY. —— —————————————————————————————————— 3 No. F, Fee 5­0 + + THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Ziopozar *p5tem Construction ermit Permission is hereby granted to to construct( )repair(..-)-a —site Sewa a System located at No.# 's r rc_ I- --- Street and as described in the above Application for Disposal System Construction Permit. 94 - -> %"7 _ S` No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. / Date: l ir Approved by V-&t i (" Board of Health w 10 } 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 comaiting the ; property located at /�5 ��c-vT��- w� �� y�'^�`' G` ` —mom$lill of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. y`• A • !t. t SIGNED: DATE: ,` O LICENSED SEPWC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a oe ti9ed plot�pian,' this plan should be submitted]. wig - .ti .�� -. ��, �,+ -� f .� r ,� d ,� x: �1T B. 'vSTABLE i� LOCATION �✓� _ ` SEWAGE it VILLAGE ASSESSOR'S MAP & 1 INSTALLER'S NAME&PHONE NO._ �'0 e Se�{zL &I(sf� SEPTIC TANK CAPACITY 79tik LEACHING FACILITY: (typ6 .L�r/fi/fis}.2�5 (size)C `�� NO.OF BEDROOMS BUILDER OR OWNER 0-4 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: I Maximum Adjusted Groundwater 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 f� .lity Feet Furnished by a!� J Ke F t46VSG 0 / /v 19i 9 0� 6 l � � 63 3 TIC♦j]'AT OF a^.+.a�.ysR�'T3Ty�K.( p.� �./ L1-11�1rJ j�""1.�.lLr: �. LOCH ON SEWAGE # VILLAGE / �, w ASSESSOR'S MAP& LOT-RV I�y'l INSTALLER'S NAME&PHONE NO. /V!S �We SW�L C ds ?,9����': SEPTIC TANK CAPACITY It-60 (54 1 ;�`VA- LEACHING FACILITY: (typ .Qf/, W/Ad S (size) C� �� Stt��re ,q�avRd ; NO.OF BEDROOMS v � � � BUILDER OR OWNyErR /l PERMITDATE: •J r COMPLIANCE DATE: '` '� -'t Separation Distance Between the: Maximum Adjusted Groundwater 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 leachin f fli Feet Furnished by, �i t,. �if12 CIF �c15� 22 1J 3 TO N OF BARN TAB�V BARNS TABLE LOCATION d Q ,C f t ,,��J,L I' d SEWAGE# 7008- 003 VILLAGE �_rrN-4 yt /t('ASSESSOR'S MAP&PARCEL A a - y INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY tS'Ug LEACHING FACILITY:(type) ZC(e 1/ 2 0 (size) i U NO.OF BEDROOMS t- OWNER 6-Q to r I A Lo-rc)rL j re- r,.Q PERMIT DATE: 1 'Z r e 8 COMPLIANCE DATE: 9 2008 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Na /J 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) f Feet FURNISHED BY C P10ew�C� C�h .aCi�t s CJL�- i e� Hf &o ptZ g 99. 1 ffq 97. 7 99 .0