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Home My WebLink About0180 GUILDFORD ROAD - Health 180 Guildford Rd. , Centerville A= 171-071 r,. No. 42101/3 ORA ESSELTE 10% 0 o 0 0 c" TR '��. Fee � I No. — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for Mi!oaal bratm Comaruction Permit Application is hereby made for a Permit to Construct( )or Repair( Kan On-site Sewage Disposal System at: Location Address or Lot No. / � ��- Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms �. 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 Description of Soil Na re of Repairs or Alter ' Ins(Answer when applicable) , V S at �l A: lsj 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 _ Signed Date Application Approved bye Application Disapproved for the following reasons Permit No. !/ Date Issued 3 0Z No. �./ � / � Lc� � Fee � THE COMMONWEALTH OF MASSACHUSETTS - L� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE.MASSACHUSETTS d Tippiication for Migonl *pgtem Congtruction Permit , Application is hereby made for a Permit to Construct( )or Repair( I<an On-site Sewage Disposal System at: Location Address or Lot No. /f cot Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. / 11 Type of Building: Dwelling No.of Bedrooms �. 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 Description of Soil Na re 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 'Wslkied by this Boar Up Signed Date Application Approved y Application Disapproved for the following reasons I Permit No. �I-I/}- t 9 2" Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(1/ )on by cO cl ^ for W Ak C,�bn, r `, has been yonsAicteh in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: ———9------_— —=----- +------ No. �� —— — Fee �� - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mto gal *pgtem Congtructton Permit Permission is hereby granted to VI to construct( )repair( c4l'ain On-site Sewage System located at G u t r- C"R.�\1 I P. 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. All construction ust be completed within two years of the date below. Date: 3 Approved by i d CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) i A. , I, hereby certify that the application for disposal works construction permit signed by me dated SJ t 3 . concerning the property located at t N --e) \ (.�J _CUkN4UM all of the following criteria: •C •L/Icx are no wetlands within 300 feet of the proposed septic system f the septic system • There are no private wells within 150 feet o proposed sept .cyst The observed groundwater table is 14 feet or greater below the bottom of the leaching facility There is no increase in flow and/or change in use proposed ere are no variances requested or needed. SIGNED: '" DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTA13LE NUMBER 5s _ y. [Attach a sketch plan of the proposed system. Also If the licensed installer posesses a certified plot plan, this plan should be submitted]. i +� /Goo r11 V C 67 J0-r— . TOWN OF BARNSTABLE C LOCATION l Q t)k k c'CCXCy SEWAGE # VILLAGE C Q I��CU l`�_ ASSESSOR'S MAP &LOT -/7/ 6 7Z INSTALLER'S NAME&PHONE NO. kA I"1 C-VCW . SEPTIC TANK CAPACITY IM0S6-L 0 20 2X CAC) LEACHING FACILrN: (type) (size) �,w� 1 �� -S3ien1__ NO.OF BEDROOMS 3 ^� s kfr,� BUILDER OR OWNER ` C—\L PERMIT DATE:_S�1 c 3 cC OMPLIANCE DATE: 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 Leaching Facility(If ands exist within 300 feet leaching facility) Q /f,�\ Feet Furnished t 0 o pBox 3� as G-Ira ax 3 0�1 � �s.��