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Home My WebLink About0136 KNOTTY PINE LANE - Health �156 KNOTTY PINE LANE, CENTERVILL A= 191-094 s No. l 7 / Fee Entered in computer: f THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pphration for Mi_qpoal *patent Congtruction 3permit Application for a Permit to Construct( )Repair(�/)Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. /J/ f Owner's Name Address and Tel.No. / t� 1✓r�o}�y n2 �� /c^ /� rio c-gin. Assessor's Map/Parcel C.C/1�-��.\sk r—N c Installer's Name,Address,an Tel.No. Designer's Name,Ad ess and Tel.No. Cc� ( \f 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 T(Z0C,,, _ eType of S.A.S. Description of Soil Nature of Repairs or Alterr ons en ��r (Answer when applicable) Ar�U rn cX 1 �C/ a ' J 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 Env' a and not to place the system in operation until a Certifi- cate of Compliance has been iss by this Board of ealt Signed Date Application Approved by Date 100, Application Disapproved for the following reasons Permit No. y 7l Date Issued 7 Z e - - - - - _ - - - - - - - - - - - - - - -- - _I f--- --------- Ll7 V i o i o(d �i�' /Ako S-k J� p E3Jx a 2 30 TOWN QF.BARNSTABLE CC-v--q.— SEWAGE # LOCATION (1 U v VII,LAGE �l%� �y� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f S '�` LEACHING FACILITY: (type) Mc X l j c•�l (size) NO.OF BEDROOMS 3 BUILDER OR OWNER L j PERMIT DATE: COMPLIANCE DATE: Str— i Separation Distance Between the: cc Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet �I Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 260 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) r- Furnished by /' TOWN'OF�BARNSTABLE LOCATION 26 "O U�'I v u r �Cy-�- SEWAGE # VILLAGE Cf "tL� ASSESSOR'S MAP & LOT C) INSTALLER'S NAME&PHONE NO. ��L< 7 rr SEPTIC TANK CAPACITY C X f S T J O C)L 6:S L ' 10 X LEACHING FACILITY: (type) McXS l T'_ Crrr,�L (size) NO.OF BEDROOMS -3 ,, BUILDER OR OWNER �// � MCP'( n PERMTTDATE: �� 1 f5 e 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 k on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of Jeaching facility) Feet Furnished by 3� o - ,; 6 a -7 � �u kiC-f 30 . 0 No. 9� // Fee J�/ ` THE COMMONWE LTH OF MASSACHUSETTS Yes Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(p prication for Migo!W *pMem Congtruction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./�l7/ �� Owner's Name,Address and Tel No. .r,O0 l Assessor's Map/Parcel Cc l_kr v ,,. r C"T t �O r t/�. JIG 1-11 \Pi.._.R ccl_k.,. C (f�tcry 1 Installer's Name,Address,an Tel.No. Designer's Name,Add ss and Tel.No. Type of Building: Dwelling No.of Bedrooms 17 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 1660 CG c P <f S t Type of S.A.S. Description of Soil Nature of Repairs or Alter pans(Answer when applicable) AC)� � t-1 C•,X 1 NM 1 � lC( F� C)'c 3�nt ,2 r� F 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 Env' ode and not to place the system in operation until a Certifi- cate of Compliance has been iss by this Board of ealt ^� / Signed Date / /ci Application Approved by Date Application Disapproved for the following reasons Permit No. q 71 Date Issued 7 ' Z ? ———————————————————7 - - ------------------ THE COMMONWEALTH OF MASSACHUSETTS r BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired'( L/1"Upgraded( ) Abandoned( )by y CKn r l Oc Z rN at kn o L l--e C l 1.' .has been constructed in accordance with the prov' �ons of T}'tle 5 and a for Disposal System Construction Permit No. �— y-7/dated 7 Installer c �\ �`'� ✓ Designer The issuance of this veejrmit s all not bvo strued as a guarantee that the system T on as designed. Date / oy - I Inspector --------------------------------------- 9�-- 1/7/No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS lwigogal *pgtemtpgrade ngtruction Permit Permission is hereby granted to Construct( )Repair( c ( )Abandon( ) 1� System located at e l^1�.... --C�..---�, 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 th*'�C:�.Date: ?_ Z 3�� Approved b r 1 7/98 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, p�� l`� �� , hereby certify that the application for disposal works construction permit signed by me dated `� s13 �<X7)S , concerning the property located at 3 I�N OAy QV-4— meets all of the following criteria: There are no wetlands located within 100 feet of the proposed soil absorption system. c /• There are no private wells located within 150 feet of the proposed septic system. There is no increase in flow and/or change in use proposed. I There are no variances requested or needed. VIf there are any wetlands located within 250 feet of the proposed soil absorption system,the observed groundwater table is 14 feet or greater below the bottom of the leaching facility. I understand that the attached Title V Calculation Chart may only be used for the design of a septic system if the existing naturally occurring soil is classified as Class I(sand or loamy sand) in the most hydraulically restrictive layer included within the five foot zone beneath the proposed soil absorption system. If the soil conditions are not Class I within this above described zone, a professional engineer or registered sanitarian is required. - SIGNED 4ADATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER Please complete the following: A)Elevation at top of ground in the location of the proposed soil absorption system B)Elevation of groundwater [Attach a sketch plan of the proposed system. Also if the licensed installer possesses a certified plot plan,this plan should be submitted]. q:health folder:Cert2 r 0 - O I (0:0) S