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Home My WebLink About1081 FALMOUTH ROAD/RTE 28 - Health =�1 Y 1081 FALMOUTH RD., CENTERVILLE A=250.006 i !1 Sll/I J��cvcc��o UPC 12534 No. 2_ 153LOR . HASTINGS, MN e ..... - - - i i { '� E i[ f V f�a-was n�7 .No. Fee�� A_ � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Mkopogal *p5tem Construction Permit Application for a Permit to Construct( )Repair(�/)Upgrade( )Abandon( ) El Complete System ❑Individual Components 1 .1',,�rnc�°J Owner's Name,Address and Tel. No. Location Address or Lot No. i ox Assessor's Map/Parcel n�� ®� oC Installers Name, e,Addreeand Tel.N Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(k) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title r Size of Septic Tank /�G Type of S.A.S. -\(� \)-cz..NU,3 Description of Soil Nature of Repairs or Alterations(Answer when applicable' C - e X 1 1 all P C)0 f J U I 15b6 6-C,k- 0 O o x S Iw Ll 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' ed by this Bo eat ! y Signed rL% L Date Application Approved by Date ��?�` Application Disapproved for We fol ing reasons Permit No. �� — 6 Date Issued - - - - - - - - - - - - No. / G1—=�[� 1• Fee�� Entered in computer: 1 THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Zi-4pooar *p!5tem Construction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel. No. Assessor's Map/Parcel [� CEO � L(30 r �( M Installer's NameCAddre d Tel.Nq. - Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms �� Lot Size sq.ft. Garbage Grinder(W Other Type of Building 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 LSd6 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �_4 0� C.2 C)6W r`Gi 6ei4 p o0 l J U / f Sao &C_l -k-G ( Q 0 o X X S w L/Of S"h•< 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 ' ed by this Boar ealth.4 Signed' G Date / v- Application Approved by Date g ? Application Disapproved for t e folio ing reasons Permit No. �� - J` w < 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 t-c e r-.P PC w-c-g_ at l0 & ! �1 c�.r datel Q-O/ 4 0 A -N- - \V1� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. .S�G 3 dated Installer r�. ��-t'-w�-I iC_. Designer The issuance of this pt��rmit shall not be construed as a guarantee that the system ill fu on as designed. Date / _� ` �� Inspector ----------------------------------- No. Fee �7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mizpoga[ *pztem Congtructfon Permit Permission is hereby granted to Construct( )Repair( `'� grade( )Abandon( ) System located at CIVI l N.v.J N\^- 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 permit. Date: -3/ - 8 Approved by ( 10/9/97 1 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, cje cs hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at /`d t -f r� meets all of the following criteria: 'There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system ✓There is no increase in flow and/or change in use proposed ✓There are no variances requested or needed. e�lf the proposed leaching facility will be located within 250.feet of any wetlands,the bottom of the proposed leaching facility will I14.t be located less than fourteen(14).feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) 30 SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert f . , �, � a `� d o � c D Av A 4,-) ��x �� p B ox -3 TOWN OF BARNSTABLE LOCATION EWAGE # a6 VII LAGE ASSESSOR'S MAP & LOT ` INSTALLER'S NAME&PHONE NO. SC SA SEPTIC TANK CAPACITY („ram L LEACHING FACILITY: ( ) 3 6'7c ,X l S (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: tf� M7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _4(i/_— Private Water Supply Well and Leaching FacilityFeet on site or within 200 feet of leachingfacility any wells exist Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feepf leaching facili /UC) Feet Furnished by