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Home My WebLink About0050 JUNIPER ROAD - Health rEA UNIPTER RD. N 230 138TERVILLE 1 T R k y! A UPC 12534 No.2..... 1�53L�O.R s�'057•GUNSJ� HASTINGS,MN I No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for �Digooal *potem Cot%truction i3ermit Application for a Permit to Construct( )Repair( )Upg de( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. � va r e t�c. Owner's Name,Address and Tel.No. �'e ev�-v e � ,e m�,$/J'r'S �,1'te de r rS Assessor's Map/Parcel eIsi 1 Installer's N e�ddress, d Tel. o.,.. r� Designer424: Addr s and el.No. k Lows v�cf o� L c 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 JS 5 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /566 QZ Type of S.A.S. 00 cA Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: � a Agreement: The undersigned agrees to ensure the construction and mainte nce of the afore described on-site sewage disposal system in accordance with the provisi t oft viro enta ode and not to place the system in operation until Certi i- cate of Compliance has be issued b is H e— Signe Date f� r/ z Application Approved by Date Z a Application Disapproved for the following reasons Permit No.0? U —D�O Date Issued No Fees] THE COMMO,_;;6EL H OF MASSACHUSETTS Entered in computer: ✓/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS 01ppfication for Migpogaf *pgtem- ohgtruction Permit Application for a Permit to Construct( )Repair( )Upgr de( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. '3 0 va.t e K Owner's Name,Address and Tel.No. CE' Cr✓c �e �I4r'IY3 `y'le�/Cr S Assessor's Map/Parcel Installer'sTeMdress, d Tel. o.. .--- Designer's N eiAddress and 1.No. ORJS /LI I. O � Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 5 Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /SdCs 4�Q. Type of S.A.S. 5-00 cz#4 is Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainte nce of the afore described on-site sewage disposal system in accordance with the provision iss o rt e of t hviro enta ode and not to place the system in operation until Certi 1- cate of Compliance has be ;issued b o He 1 SigneA Date a '16 6 Application Approved by Date z 116 O Application Disapproved for the following reasons Permit No. �qU 0 1 " 0�0 Date Issued --------------------------------------- -Z THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERUEY, t/heat the O -site ewage Disposal System Constructed( )Repaired()! )Upgraded( ) Abandon( )by � tt �o.✓Ar�c4, o &j at 17 O ✓Au I �. has been constructe a cordance with the provisions Title 5 and the for Disposal System Construction Permit No. `�°` dated L 0 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will f notion as designed. Date �1 M 1/0 ) Inspector Y J�lf k1, ——� ----———————————————————————————————— Q No. �y 1 / '—_ Fee_I ,` Z3 G _.� j _ _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogal *pgtem Congtruction Permit Permission is hereby granted to Con truct( )Rep ' i(`')Upgrade )Abandop(/ ) System located at �l'Nler✓ �/ E v 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 Date: Z �G 2d� -A roved b %JJ(/ PP Y 116/99 NOTICE: This Form Ys �o Be Used Fo r the Repair Of Failed Septic Systems Only. r R CERTIFICATION Of SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) h '4'r. , hereby certify that the application for disposal works construction permit signed by me dated 0 concerning the r: property located at meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. (i The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. Q/• There are no wetlands within 100 feet of the proposed septic system Vo 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. t-• The bottom of the proposed leaching facility will not be located less than five feet above the maximum s adjusted groundwater table elevation..[Adjust the groundwater table using the Frimptor method when applicable] U• 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 ,3 j +the MAX. Nigh G.W. Adjustment. 0 DIFFE WEEN A and B SI DATE: Q [Plea etch pro used pl of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert ® ,II OuUf uJAs sqpcu e ec 40 Z o 64 toe f 1 5 at TOWN OF BARNSTABLE LOCATION St/L%J52 "O�V SEWAGE # c�)00 I— 09 0 VILLAGE Q-iL'22 ASSESSOR'S MAP & LOT c23C3' ' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 02 (size) (7; NO.OF BEDROOMS o2 BUILDER OR OWNER PERMITDATE: . COMPLIANCE DATE: J�Lo Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom ofLeaching Facility Feet Private Water Supply Well and.Leaching Facility (If any wells.exist.: on site or within 200 feet of leaching facility) Feet j .,Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet j Furnished by - OH .. a r A _ 'r 14 _ r /C O .. ,3 �13 .p i i i : i TOWN OF BARNSTABLE LOCATION - SEWAGE # d`�UI 0 VILLAGE CAK24-AL b4r- i ASSESSOR'S MAP & LOT o23U-)A INSTALLER'S NAME&PHONE NO. Via,S SEPTIC TANK CAPACITY - /®oo olo-ll LEACHING FACILITY: (type) 02 370� C`: (size)�� NO.OF BEDROOMS cZ BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: 6i 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 u Furnished by qi c2 a 0 N � F e— r /c:0 13 j-3 �