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HomeMy WebLinkAbout0268 MONOMOY CIRCLE - Health 2�8 MUNOE-VTOYCIRCLE CENTERVILLE A = llll UPC 12534 ' No.215 OR4�r,,�e HASTINGS, YN TOWN OF BARNSTABLE LOCATION b L SEWAGE # VILLAGE C' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /11/in C/l .�'� SEPTIC TANK CAPACITY /0'-9 r CHING FACILITY: (type) L42 f i��.Q TO (size) S-LIZOF BEDROOMS w. BUILDER OR OWNERF i PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leachingifacility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 4 i � oil 9. No. —� ✓' `j�. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -� es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE.,Zipplication for igogaYpgt rrt Congtructior� hermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 0 Complete System Individual Components Location Address or Lot No (ADP O ike t f C. Owner's Name,Address and Tel.No. - k� Assessor's Map/Parcel b/ /�d �t C? -C Installer's Name,Address,and Tel.No. ` Designer's Name,Address anV 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 C O gallons per day. Calculated daily flow `-N7 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank "ti ®0® Type of S.A.S. \ c� Lr Description of Soil nll. in Nature of Repairs or Alterations(Answer when applicable) D— jt- --, Date last inspected: ail 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"IR Signed Date Q 14 C. Application Approved by Date Application Disapproved for the following reasons Permit No. 7Y--s—o"76 Date Issued. Fee THE COMMONWEA fT QF, MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION TOWN OF BARNSTABLES MASSACHUSETTS } � opricatiott for Mig oga[ *Pgtem Congtruction Permit Application for a Permit to Construct( )'Repair( )Upgrade( )Abandon( ) El Complete System &Individual Components i Location Address or Lot Noc Owner's Name,Address and Tel.No. Assessor',s Map/Pazcel \Ci V— D`0 Installer's Name,Address,and Tel.No. Designer's Name,Address AA Tel.No. II�ifJs-c. rR(Y St=�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 C-t(`t gallons per day. Calculated daily flow C1 gallons. Plan Date .„ Number of sheets Revision Date i Ti 1 Size of Septic Tank !E;<% c c\;C Or Type of S.A.S. c. e Lr� Description of Soil • a Nature of Repairs or Alterations(Answer when,applicable) =j_L S tt a� � �ec.�� D—aC--,e i It I S S' ov ae -e e� 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 begg.isskto" h. Signed Date � �C Application Approved by Date Application Disapproved for the following reasons Permit No. � Date Issued ------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS r °� Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded((,-< Abandoned( )by at - G " has been constructed in accordance with the provisions of Title 5 and the f4 Disposal System Construction Permit No. `fig_7 1& �ated, r R Installer Designer ": 4 The issuance of this permit shall nk be construe as a guarantee that the sy t �will function as depfgne /` II Date f t ( , Inspector i'11 .ram_.- m r --------------------------------------- No. O Fee J" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( Abandon( ) System located at 16 R/tc C%, (p 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 mustbe completed within three years of the date of thi ermit. Date: / —/ / Approved by 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 certify that the application for disposal works construction permit signed by me dated -9—ci�l concerning the property located at DLOD -W t-V 4 C-' meets all of the following criteria: V • The failed stem is connected to a residential dwelling only. There are n system g y o commercial or business es associated with the dwelling. e 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 ma..dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] 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 ma..cimum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation 35;0+the MAX High G.W. Adjustment f rf _ S6'LF— DIFFERENCE BETWEEN A and B SIGNED : DATE: (Sketch proposed an of system on back]. q:health folder,cat J - � 1 TOWN OF BARNSTABLE �c LOCATION ..n SEWAGE # VILLAGEZ ' 1 ASSESSOR'S MAP &'LOT INSTALLER'S NAME&PHONE NO. i_ l SEPTIC TANK CAPACITY /a'o© I LEACHING FACILITY: (type) .2 O (size) l NO.OF BEDROOMS BUILDER OR OWNE PERMTTDATE: 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 elf any wetlands exist within 300 feet of leaching facility) Feet Furnished by r 1 W f Y