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Home My WebLink About0022 JACQUELINE COURT - Health (2) 22 JACQULINE COURT, CENTERVH LE A=210.179 i ,.. .A, No. �1— l ' Fee �7 � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Migozal 6pgtem Congtruction Vermit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System individual Components Location Address or Lot No.C—);;L �Sfj(&-V \&gz_4fZxA77_ Owner's Name,Address and Tel.No. Assessor's Map/Parcel -Z f — '.7 1GY4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures U Design Flow ��b x gallons per day. Calculated daily flow 3 19 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank f &-t r ,,'o Type of S.A.S. t Description of Soil S`� Nature of Repairs or Alterations(Ans er 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 bee Hea _t�'�� Signed Date cy Application Approved by Date Application Disapproved for the following reasons Permit No. q ' 7 Date Issued -7- — 7" No. / — `...,,,.s Fee -5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes 0[pprication for Di!gponl *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(vloAbandon( ) ❑Complete System ,'Individual Components Location Address or Lot No. � �3 U \o��,�v � Owner's Name,Address and Tel.No. Assessor's Map/Parcel /a — '1-79 G y2K* Installer's Name,Address,and Tel.No. Designei:'s Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_3 Lot Size sq.ft. Garbage Grinder'( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow d gallons per day. Calculated daily flow 3 A9 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank o9o., Type of S.AS.14t Grc Gt d Tr�'rd�C Description of Soff Nature of Repairs or Alterations(Ans er when applicable) �tF-� -\\ �- � �fi,�C`��t i' 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 be d f HeaL Signed Date 7 Application Approved by Date Z-/_7'.�9 . Application Disapproved for the following reasons Permit No. q 9 ' Date Issued 2 —/ - --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS j.� )1' BARNSTABLE, MASSACHUSETTS (Certificate of QCompliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded ) Abandoned( )by W11 o-GV9 Sa Oxic, at tea• auS,w-t ccv'2-,�- � ✓.,� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. T� ' 7 dated Z _/7—)1{' Installer Designer .\ The issuance of this a 't hall of b onstrued as a guarantee that the sysfell, unction as desi .6 Date , Inspector �' Y ————————————————————————————————————� V-- -— No. 9 7 — -7( Fee X , `7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS ]0i5po5a1 *p5tem (Construction Permit Permission is hereby granted to Construct( )Repair( Jpgrade( )Abandon( ) System located at (C,C1y4� t'n y`r-7 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 it. Date: Z l 7` ( q Approved by i �� s. 1/6199 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 DESIGNED PLANS) I, hereby certify that the application for disposal works construction permit signed by me dated v�_ 1� CL 1 concerning the property located at 7S1AC(RD \f ul� cou`� meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. l/The soil is classified as CLASS I and the percolation rate is less than ore equal to 5 minutes per inch. q�/-h Tere are no wetlands within 100 feet of the proposed septic system P (�There are no private wells within 150 feet of the proposed septic system C/There is no increase in flow and/or change in use proposed CJ' There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation.I[Adjust the groundwater table using the Frimptor ethod when applicable] • If 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 �c�+the MAX.High G.W. Adjustment Le 11, = env c DIFFERENCE BETWEEN A and B t 0 SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder:cert �.g'J`" �. � .�. i C7 --�. .� ,.. u TOWN OF BARNSTABLE LOCATION SEWAGE # ' VILLAGE ASSESSOR'S MAP& LOT �9 INSTALLER'S NAME&PHONE NO._ fit. - SEPTIC TANK CAPACPTY LEACHING FACILITY: (h' ) %�`� r (size) NO.OF BEDROOMS BULL DER OR OWNER PER.?dTTDATE: OMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and LeachingFacility ty (If any wells exist } on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet I i TOWN OF BARNSTABLE � LOCATION n�� rf��C'ff/z LlWi on, v27— SEWAGE # VILLAG ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. ,/J't_ i, Ci'!.D SEPTIC TANK CAPACITY d C7 LEACHING FACILITY: (ty 71r.4 tgt T (size) NO.OF BEDROOMS BUILDER OR OWNER PER1,41TDATE: OMPLIANCE DATE: ti J S,eparation Distance Between the: ' - Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Privite 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 r _ i a - 1 C, �.a r t --� 1 60-0 � J V our � si u� Z��►i C � 4 i i J _ Insvlat\oh �o -rs 13 Flo Kr. 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