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HomeMy WebLinkAbout0017 DONEGAL CIRCLE - Health7A=17 D09EGAL CIRC. 9CENTERVILLE 169-022 1 1 TIIBIKz uu NoPr 53,5C�OR KASTINOS.UN No. 97 - Fee 7 i�tz5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migaar 6potem conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade(V)Abandon( ) O Complete System 106lividual Components Location Address or Lot No. , 7 6����Q Owner's Name,Address d Tel.No. Assessor's Map/Parcel CeAlv'�� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /- 3A' Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( � Other Type of Building IeA ,r,�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 /44®tZ OVI 46r b �f Type of S.A.S. 1geZWZ Z Description of Soil 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 b this Board of ealth. / Signed Date l/6`Q Application Approved by Date Application Disapproved for the following reasons It Permit No. ''' Date Issued ff o. Fee � N ' THE COMMONWEALTH OF MASSACHUSETTS `.Entered 5ncomputer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 2pprication for Migpooar *pztem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade(�')Abandon( ) O Complete System 9?15dividual Components Location Address or Lot No. / 7 ��� � >��f� Owner's Name,Address apd Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. UDC 7`®G® i /-e3eQ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building C-Ve2fNo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 33eP gallons. Plan Date Number of sheets Revision Date 4.9- 'e Title Size of Septic Tank ©�� �'l° GXl3�` '��' Type of S.A.S. Z Description of Soil Nature of Repairs or Alterations(Answer when applicable) of 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 Bo-ard of liealth. Signed Date fQ/6le7 Application Approved by Date �r Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE�41FY, that t e On- ite Sewage Disposal System Constructed ( )Repaired ( )Upgraded( ) Abandoned( by /�d��� ` �✓`- at /7 oft .9 has beep.constructed in acc rdance with the provisions of i'de 5 and the for Disposal System Construction Permit No. dated Ig ''/417 7 Installer Designer The issuance of this permjt shall not be construed as a guarantee that the system will function as designed. Date —1 - .Gi - Inspector F� No. / / L� ------------------= �C7C ©ZG^' Fee 4-1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mizpozal *p!6tem Conztru�tion Permit Permission is hereby granted to Construct( )Repair( Upgrade(✓)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 Date: / `�! r Approved b i� NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLIC aTION FOR A DISPOSAL WORKS CONSTRUCTION PERIMIIT (`ZTTHOtiT DESIGNED PLANS) i ���/y�/`I/ e'e��' ��'riI`% :�'iai he arri;caLion LOr Z1Sresa1 '-Voris -ons%cticr ce..r-L :snec -once r Vie-^; ,�c�ted 3L 17 blwe, 4'! cm/ le—, W 1 - -- - >142�ATF. ll/G LICENSED SEPTIC SYSTEM.INSTALLER Ili=t?E TOW N. OF BARNSTABLE LUMBER [attach a sketch plan of the proposed system. Also if to licensed installer aosesses a terrified plot pian. this plan should be submitted]. 0:haft Lol l i C' I I ' I I i I j I I _ h I. I /L CSC TOWN OF ARNSTABLE / i LOCATION 7 D0nepQ/c��7 SEWAGE # 97�J`�lb VILLAGE Ce-&' 7/� ASSESSOR'S MAP & LOT AI��2Z INSTALLER'S NAME&PHONE NO. �G�T G C ,�r5�% T 71 !3, SEPTIC TANK CAPACITY 00//0 LEACHING FACILITY: (type) .Lw��L bra fekS ��� (size) NO.OF BEDROOMS i i .BUELDER O O dR PERMI'TDATE: IA COMPLNCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility L5t Feet j Private Water Supply Well and Leaching Facility (If any wells exist 'on site or within 200 feet of leaching facility) q Feet Edge of Wetland and Leaching Facility(If any wetlands exist A within 300 feet of leaching facility) Feet 1 Furnished by j qh j q bl i Glie TOWN OF/BARNSTABLE ` LOCATION 17 Oowepel el�/�` SEWAGE # /®7'.-lb/ VILLAGE CPie)w� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ��I� i-e 7 SEPTIC TANK CAPACITY 1,000 LEACHING FACILITY: (type) -Lw (size) 10'X3d'3e_A NO. OF BEDROOMS BUILDER O OWNER ��`9' PERMITDATE: COMPLIANCE DATE: `1'—� '� 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 LeachiniF c lity,(If any wetlands exist s� within 300 feet of leaching facility"),_� Feet Furnished by. �' �e dtk— r c Dc c �b