HomeMy WebLinkAbout0135 CLIFTON LANE - Health 135 Clifton Lane
Centerville
A= 247-121
S M E A D
No.2453LOR
UPC 12M
awmadAom • Umb is WA
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THE COMMONWEALTH OF MASSACHUSETTS Entered in comp ter:
o. Fee
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PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippliLation for Disposal 6pstrm Construction 3pPrmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Cfj' �� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel o
Q, 'ea
Installer's Name,Address,and Tel.Nod4dV;, A-L Designer's Name,Address,and Tel.No.
o,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)_
Date last inspected:
Agreement:
The undersigned agrees to ensure the const ct' n an maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of th v' o enta Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board eal .
i e o Date � �-
Application Approved by Date
Application Disapproved by Date
for the following reasons
00
Permit No. Date Issued
No. / _ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in comp ter:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitatibn for Misposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. j ��62A I Owner's Name,Address,and Tel.No�aQ�,
Assessor's Map/Parcel
Installer's Name,Address,and Tel.NoC/4<_-?j/U4 _rl Designer's Name,Address,and Tel.No.
C! I
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 't
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank l 1i A L- Type of S.A.S.
Description of Soil y
Nature of Repairs or Alterations(Answer when applicable) �_ .Q
'Date last inspected:
Agreement: /
The undersigned agrees to ensure the const ct•bn an maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of th v' o enta Code and not to place the system in,operation until a Certificate of
Compliance has been issued by this Board eal
i ed AA o Date f 7
Application Approved by ® Date j
Application Disapproved by Date
for the following reasons
�.
Permit No., Date Issued J
t THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance,
THIS IS TO CE FY,that the On-site See Disposal syst Constructed( ) Repaired(� Upgraded( )
Abandoned( yby Q
at �7 C l G,/l1 /(i� has been constructed in acc ce
with the pro ' ions of Title 5 and the f Disposal System Construction Permit No _� c ted
InstallerG�64,4/!7� ���i6y�J Designer /
#bedrooms Approved design flow gpd
The issuance of this
�permit
/s�h 11 not be construed as a guarantee that the system will function as-d se aged.
Date Inspector
-----------�--------y ---- --------- - .. - --------------- --------- ------- --- --------- -----
-
No. W � 7 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction permit
Permission is hereby granted to C9,nst ruct( ) ga'r )/ >iJpgrade( b�don( )
System located at �/J /
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Cons btion mu t be completed within three years of the date of this permit I
D� f7 Approved by / l
tl
` TOWN OF BARNSTABLE
LOCATION/ /�' Ci/�/ ZAL • SEWAGE# `Z y
VILLAG ,/4 ASSESSOR'S MAP&PARCEL c9y 7—,/�;-
INSTALLER'S NAME&PHONE NZ WQ i tgt
SEPTIC TANK CAPACITY g,411Pw
LEACHING FACILITY:(type) 4
'� �� (size)
NO.OF BEDROOMS ,/
OWNER 7J
PERMIT DATE: COMPLIANCE DATE:
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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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