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HomeMy WebLinkAbout0133 COTTONWOOD LANE - Health r 133 Cottonwood Lane - Centerville A = 252 - 031 S M E A D'I No.H163OR UPC 10259 smead.com • Made in USA 00-Yasleb viv f� TOWN OF BARNSTABU ay"t J LOCATION C�GtiG �� SEWAGE# OZ06 3 T VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I sd LEACHING FACILITY:(type) — ,2(size) r NO.OF BEDROOMS OWNER 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 la'2 No. � C O I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplicatiou for W5pogar *p91euY Cou tructiou 'Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑.Complete System J�Individual Components Location Address or Lot No. ��j Owner's Name,Address and Tel.No. Assessor's Ma�arc�l 6 e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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) t✓A— 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 f Repairs o Alterations(Answer when applicable) �-{� ®41 �a/� 6y 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 Enviro ntal de and not to place the system in operation until a Certificate of Compliance has been issued by this Board e h. Signed Date 3 v Application Approved by Date N " _ Application Disapproved by: Date for the following reasons Permit No. 0 Cl U 6 K Date Issued ----------�----_—---',rat------- --- o0►_ o,� - No. C -» rt Fee�— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH.DIVISION - TOVIWN.OF BARNSTABLE, MASSACHUSETTS Yes ` 01pptication for �N,50o5al 4v5tem' Con0truction Permit \ Application for a Permit to Construct( ) Repair(10)' Upgrade( ) Abandon( ) ❑.Complete System ®`Individual Components Location Address or Lot No. / 3 C,0�Q,o&iT96*41of Owner's Name,Address;and Tel.No. o u Assessor s' Map/Parc I e / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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) ►v gpd Design flow provided /t/ gpd Plan Date" Number of sheets Revision Date Title Size of.Septic Tank Type of S.A.S. Description of Soil � •ti Nature of Repairs WAlterations(Answer when applicable) � � o 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 C•21e and not to place the system in operation until a Certificate of Compliance has been issued by this Board ?f; Signed n Date- Application Approved by ' - Date 9 ~- l ? Application Disapproved by: U Date for the following reasons t . Permit No. d-D B d Date Issued t_1— "D �n THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS lx r �'` `/' Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Dis osal System Constructed ( ) Repaired (v)XUpgraded ( ) Abandoned(z )by Z�,CW /Cam'(d l/ l at / °3-3 ©</G�k��'�� Av e::1hw,,b en onstructed iyn accordance O� with the provisions of Title 5 and the for Disposal System Construction Permit No. goo ! O O dated -1 1� Installer Designer #bedrooms Approved design flow /V gpd The issuance of this pert it shall not be construed as a guarantee that the system11 fu/nctiotnnas�design/e�d.� c Date I VI 0Cl Inspector �I� -—— No. `� �^ Fee---''-�-'c �-. �_ THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC-HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Mi5po5al 4§p5tem Con.5truction Permit Permission is hereby granted to Construct ( ) Repair (/� Upgrade ( ) Abandon ( ) System located at �; �d//D 1 /,ff and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this�perm-I Date / Approved by i