Loading...
HomeMy WebLinkAbout0160 FOX HILL ROAD - Health 160 FOX HILL RD., CENTERVILLE A = 190 043 Dui 14 'ACYCQrpf& UPZ 2 4 • Naarurvi.w* 3 No. 6 Fee " THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppricatiou for Mioozal *� /pztem Conztructiou Permit Application for a Permit to Construct( )Repair( )Upgrade(�/)Abandon( ) Y omplete System ❑Individual Components Location Address or Lot No. 14® Y `Tj 1 11 r� Owner's Name,Address and Tel.No, Ci&il✓t7`'e l Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �prl©Iye1 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(A® Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 11119 gallons per day. Calculated daily flow 3 3Z7 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 73 el Type of S.A.S. 4, —!// 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 his Bo of alth. >�/� Signed p Date / Application Approved by ✓J Date _317-0" Application Disapproved for the following reasons Permit No. Date Issued No. W"� Fee sZ), Y = THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSET7S 01ppfication for Migpogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(P Abandon( ) 19Complete System ❑Individual Components Location Address or Lot No. wners O ' Name,Address and Tel No Gera/�:S��r/may. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. C• Designer's Name,Address and Tel.No. 80r ��o////'C©0-,e,It,- - 77 - 9 99 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 //0 gallons per day. Calculated daily flow 3 34 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /S ew Type of S.A.S. i Description of Soil ;7 ' Nature of Repairs or Alterations(Answer when applicable) 41l�Q/!1 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 his Board of fjplth. Signed Date ,311411ey Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 3 BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On ite Sewage Disposal System Constructed( )Repaired( )Upgraded(✓) Abandoned/( )by at �p© OW/l has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector -------q-----------------------�—------('�-- ) No. /� /�/ `ael3Fee "�Y ) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ligpogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(Abandon( ) System located at ��� f fx �/�l ✓�' 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 t. Date: Approved by r TOWN OF BARNSTABLE• LOCATION l Gf SOX. SEWAGE # Z01PO7W VILLAGE G �1lYY�(/>��� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO._0d001011-1 SEPTIC TANK CAPACITY IS—do 61L LEACHING FACILITY: (type).Z�X'f Av 1 s 00 (size) NO.OF BEDROOMS 3 a } BUILDER OR OWNER �kde PERMITDATE: JZO T 4�1� COMPLIANCE DATE: 4 3 to Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Sf 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 /.SCE' jery I PO c ' 7, all/ • 30' 1/6/" 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 PERINUT (WITHOUT DESIGNED PLANS) L ����r�� A D/'7�/e ereby certify that the application for disposal works construction permit signed by me dated ��Z�/®� concerning the property located at /elB /��X 21/ 6eel-Je/l//110ets all of the following criteria: V/ The failed system is connected to a residential dwelling only. There are no commercial or business es associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system ere 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. }/The bottom of the proposed leaching facility will not be located less than five feet above the ma..-dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] lif the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation Z5 +the MAX High G.W. Adjustment.Z3 = Z -7 i 3 DIFFERENCE BETWEEN A and B ' a SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder.cert i i I 1 = t J � �q r