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Home My WebLink About0054 JAMES OTIS ROAD - Health 54 JAMES OTIS RD.,CENTERVILLE A=171-166 c. r• 3 � UPC 12543 No. 53LOR +lt�5.CoNco HASTINGS, MN / Cr •No. 6 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprication for �igpool 6pgtem Congtruction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No..2—5 yl an Owner's Name,Address and Tel.No. Assessor's Map/Parcel q-I I.:,16,Q '�—P(J vT'G C js 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 Design Flow �O gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �,, '% b A- Type of S.A.S. � .11 Oct"(ct"( V Description of Soil im- S� Nature of Repairs or Alterations(Answer when applicable)_VV S_4'\ G4�\ 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 b e y tht ealth. Signed Date,. Application Approved Date(/ _. Application Disapproved for the following reasons Permit No. A G Date Issued — —� TOWN OF PARNSTABLE LOCATION ✓` SEWAGE # 11, VILLAG ASSESSOR'S MAP& LOT 7 INSTALLER'S NAME&PHONE NO. M i n C,f✓>A d C 7 2 9�-'f SEPTIC TANK CAPACITY /S-610 LEACHING FACILITY: (type) i ✓7e'l L IkA70,C S (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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 within 300 feet of leaching facility) Feet Furnished by I �3 J/ a /J4 , A 3 92 t 1 . No. �j .�j < .'�i✓ c Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes , PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS I 3pprtcatton for �Btopozar *potem Congtructton Vermt't Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No..5-2-_�t/.�(S>Qom(>a Cr Owner's Name,Address and Tel.No. Assessor's MaOarcel 1 i ''` Installerr'ss,Name,Address, land Tel.No. Designer's Name,Address and Tel.No. �0 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 CD gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. C�`l!;it !N -�c,�N Description of Soil -Q S Nature of Repairs or Alterations(Answer when applicable) u S1 to \ 0+��' 0'60(,< r 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 e y t I ealth. <-� Signed Date ) Application Approved Date 4Z Application Disapproved for the following reasons Permit No. Date Issued ✓' --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTSf, (ferttftcate of Compitance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(VI Abandoned( )by VVIII Q—G$A 42 C`e��a( at nk k N` c, v-w2 �-, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. F '4 dated Installer a Designer /" 11 Ar^ The issuance of this e�mitsh 1 iot a construed as a guarantee that the s/ry tem wil�l/function as des, ned. Date Inspector ------------------------------- No. Fee-,.� 25 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'WtOogal *pgtem Con.5tructton Vermtt Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at s3 ::y Ig by CS 67 t S 90 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 t 6 rmit. Date: Approved � � -C7 1/6/99 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) hereby h certify y that the application for disposal works construction permit signed by me dated a -'cl , concerning the property located at 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. • 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 • 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. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method 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) (Ot �v Vt ct B) G.W.Elevation /"" +the MAX.High G.W. Adjustment. _ �� DIFFERENCE BETWEEN A Od B SIGNED : DATE: �� [Sketch proposed plan of system on back]. q:health folder:cert i G c?