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Home My WebLink About0100 FULLER ROAD - Health 100 FULLER RD.,CENTERVILLE A=189.117 No. 4214 1/3 ORA ESSELTE 10% 0 0 0 0 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Mi-opozat bpfstem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Loc Address o1J�ot� Owner's Name,Address :�t4 Assessor's Map/Parcel ^_� l m, 1 /8'� -- ri ? J z Installer's ,_Address,and Tel.No. Designer's Name,Address and Tel.No. J /k&-L.- T3 a 45 3v 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 gallons per day. Calculated daily flow gallons. 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) v 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 e f the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this o d of He Signed A Date/ Application Approved by Date Application Disapproved for the ollowing reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: j Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migpogar *pgtem Construction 13ermit Application'3for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components t �s Location-'A ress or t No /� /J Owner's Name,Address Te o. f Assessor's Map/Parcel ! �( ^7 v — Insta`ller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3v 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title , Size of Septic Tank Q Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �UV i Date last inspected: � Agreement: l t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of�itle 5 f the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issued/by this o c_of-Deal �s Signed // Date Application Approved.by'"" Oa Date Application°Disapproved for the ollowing reasons Permit No. Date Issued THE COMMONWEALTH f MASSACHUSETTS BAR ,,,BL-t- (MASSACHUSETTS tame of (compliance THIS IS TO CERTIFY, th he On-bite,Sewage Disposal System Constructed( )Repaired( Upgraded(. ) (AI L A�`baandoned( )by i at f - h ben constructed in accordance 1 with the provisions f Title y'a d the for Disposal System°Co s c rmit No. Q' dated Installer-- t1_4 'C '�Designer 1- The issuance of this permit shall of�e construed as a guarantee that the system will function as designed. Date i -- ' ~ Inspector --- ———————————————————————————— No. Fee—�` ..-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS x1i6pogal *pgtem Construction Vermit Permission is hereby granted to Construct( )Repair Up rade( Aba ( ) System located at /CEO .r.�� 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 mu(ttbe com leted within three years of the date of t permit. // p Date: _r Approved by' / /�/ 1A rl Yl i �1,4 1 �e-' !' \1 f ' 1019/97 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) hereby certify that the application for disposal works construction permit signed by me dated /Z- f , concerning the property located at 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. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=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) 3 B)Observed Groundwater Table Elevation(according to Health Division well map) 5 SIGNED : Oz AP'0." DATE: LICENSED SEPTI 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.ccrt I s Ocl `� - �� X2 ASSESSOR'S MAP NO. 1f `1 PARCEL �� 7 LOCATI0-N$� {� p 51W :A•�Gs PERMIT NO. VILLAGE V V INSTA LLER'S NAME i ADDRESS i G BUILDER t OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ll � � , `�f �'i� � e.�-i � ��'° �s,.,,,........,� . . A�l� ��4 � TOWN OF BARNSTABLE Ir• t LOr I_.nciN �p SEWAGE # VILLAGE ASSESSOR'S MAP& LOT 13 If] INSTALLER'S NAME&PHONE NC: '<J SEPTIC TANK CAPACITY LEACHING FACILITY: (type) c)- (size) NO.OF BEDROOMS ' a /` BUILDER OR OWNER.* �J •PERMTTDATE: f I , g 2 COMPLIANCE DATE: Separation Distance Between the: ,IMaximum 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 Fut-11'shed by 'l ` J, y�e „ca v ( ,a .� ° C` Ii ' -, � y TOWNS OF BARNSTABLE � L' LOCATION SEWAGE #,Z- 7 / 9 VILLAGE ( ;C�e— n ASSESSOR'S MAP & LOT1 _ INSTALLER'S NAME&PHONE NO-. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO.OF BEDROOMS C BUILDER OR OWNER �— v PERMITDATE: I! - 9 ✓ q COMPLIANCE DATE: Separation Distance Between the: 4 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet j 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 f' within 300 feet of leaching facility) ��/ Feet Furnished by TOWN OF BARNSTABLE LOr,-'.n iq -lam:yam_ SEWAGE # 1"! LAGE � - ASSESSOR'S MAP & LOT IO 11 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) yG (size) NO.OF BEDROOMS BUILDER OR OWNER PEFMITDATE: l q q COMPLIANCE DATE: 1/ f 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 Feet within 300 feet of leaching facility) ' -- Fut-ushed by 3J ID 'A