Loading...
HomeMy WebLinkAbout0067 MAUREEN ROAD - Health 67 MAUREEN R a k.p CENTERVILLE A = 228 061 UPC 12534 No. 2_,153LOR s�n•�oNS�� HASTINGS, MN No. / U 6� +/ Fees/eL� TH'f COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippricatiou for Migoot *pgtem Cow6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ` .(/k/'E �� Owner's Name,AddreAs and Tel.No. ,[ (ems o yljt q,�2 QK d c./ ! C o Z l 2 Assessor's Map/Parcel not I / v E[f J Installer's Address,and Tel.No. 7 947 7—S`S Ll Designer's Name,Address and Tel.No. JY�t�ape, � U o a-1- Type of Building: Dwelling No.of Bedrooms 13 Lot Size 1 7 sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures aS Design Flow . gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(An&w"when applicable) 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 Environmental Code and not to place the systerr`in operation until a Certifi- cate of Compliance has been issLWd by is Boar Health. Signed _ Date ~�--X Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No. !J � _ FeeL THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopmat *pztem ConMrurtiou Perron Permission is hereby gran ed'to Construct( )Repair(4-f bpgrade.( )Abandon( ) System located at 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 cpo-mpleted within three years of the date of thiI sS- t. Date: / C1 Approved b r� No. / U Fee �< THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4 - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS Application for 30igogar 6petem Construction 'Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / G", U'e e e Owner's Name,Add r s and Tel.No. Assessor's Map/Parcel 2 Installer's Name,Address,and Tel.No. 7 CV p L ;'S 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 .j d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date TitleL.� Size of Septic Tank � Type of S.A.S. :y Description of Soil it r Nature of Repairs�or`Ajterations(Ansmr when applicable) Gt t' l C7d �t Datlast'inspected: �xt t� `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- V. 1. cate of Compliance has been iss d by s`Bbard Health. p c Signed..- `<` '�, .. Date Application Approved°by� � h_ of, Date Application Disapproved for.the following,reasons� _ Perrtit.No. Date Issued ----°----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( Z—)`Upgraded( ) Abandoned( by / at / has been constructed in accordance with the provisions of Title 5 and the for Disposal System onstruction Permit No. dated r Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date f o - 1 - !pS Inspector '1 1 Q/9/97 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 ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at ti/\� lz"—e v� �� , meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility 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. �f the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) _©_ ® I B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: 5, LICENSED SEPTIC SYSTEM INSTALLER IN E TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cent i GJ7>� a?box