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Home My WebLink About0555 OLD STAGE ROAD - Health 555 OLD STAGE RD., CENTERVILLE A=191-002.001 .711/I UPC 12534 No.2 "� HASTINGS.MN 1 a i TOWN OF BARNSTABLE ®e, LOCATION 555� ow &S,C4, SEWAGE# VILLAGE C ju-,�—J-V l,&C_ ASSESSOR'S MAP & LOT A -ml INSTALLER'S NAME&PHONE NO. av� �-�ti��, ' _2 23 1-52J 9 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) la Q4 4 !�- (size) Z ckroor d I y'��1".5 NO.OF BEDROOMS�,L U�u1e1' BUILDER OR OWNER e- C' PERMTTDATE: l 10 !C?9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 1 within 300 feet of leaching facility) —1 Feet Furnished by 3 A , ��o� No. !l 1 . Fee '. THE COMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Mi.5pogar *p5tem Construction Permit Application for a Permit to Construct(;Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No.Sj `� O.ner's Name,Address and Tel.No Assessor's Map/Parcel / r ®oj 00 Installer's Name,AddWss,and Tel.VC-1 Designer's Name,Address and Tel.No. 0V\ �� rG�n 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 Type of S.A.S. Description of Soil Nature of Rep irs or Alterations(Answer when applicable) _� C�(�G.C� T�t�1TfZ. nir 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 Envir al Code and not to place the system in operation until a Certifi- cate of Compliance has been iss%ed by this Boar o lth. Signed Date Application Approved by Date 3 l� Application Disapproved for the following reasons Permit No. �l� Date Issued 3 l N Fe THE COMMONWEALTH OF MASSACHUSETTS Entered in comp to PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETT Yes F vv 0ppYication for Mgpogar *pgtem (fongtruction Permit- Application for a Permit to Construct((/jRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.SS'� O O ner's Name,Address and Tel. o DUd Uo `,r-us .�o�s '�Mr> Assessor's Map/Parcel V, C'C Q I� CK�K (�� /'��``, Installer's Name,Add ,and Tel. Designer's Name,Address and Tel.No. t V, l Sc�� 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 t l gallons per day. Calculated daily flow gallons. Plan Date 1 /` Number of sheets Revision Date Title Size of Septic Tank /�01� Type of S.A.S. 44��. - Description of Soil y - Nature of Rep 'rs or Alterations(Answer when applicable) c t 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' tal Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed by this Boar o lth. / Signed Date ��/d / � C/ Application Approved by Date 3 �,I° ar Application Disapproved for the following reasons Permit No. Date Issued l° 9 v' —————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired (L//)Upgraded( ) Abandoned( )by k w'\ re_5 c-*-- at—vim: GNOE 5k-4 J (' V�t P,— has been constructed in accordance with the provisions of Title 5 an4the for bisposal System Construction Permit No. 2?��}� dated 3 �v Installer 'L_ C Oki ^-, Designer The issuance of this pe h ' shall no 9be c nstrued as a guarantee that the system will function as designed. r Date Inspector 1 /�?7 / ! ¢ 4 --------------------------------------- No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mwi.gpogar *pgt Congtruction Permit Permission is hereby ranted to Construct( )Repair')Upgrade( )Abandon( ) System located at 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 becompleted within three years of the date of this t. Date: Approved/ Approved by w TOWN OF BARNSTABLE ®�, LOCATION J SEWAGE # 1 VILLAGE C � f U C ASSESSOR'S MAP & LOT : 'MI INSTALLER'S NAME&PHONE NO. �l� �! ✓L S SEPTIC TANK CAPACITY LEACHING FACILITY: (type) f (size) l•J 1 L.�� - NO,OF BEDROOMS v� BUILDER OR OWNER (' PERMIT DATE: 3 1 l d i � COMPLIANCE DATE: 3 O `T Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist N Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist �SV within 300 feet of leaching facility) V Feet Furnished by P -- i � �� 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) ("t �Cm Ak, , hereby certify that the application for disposal works construction permit signed by me dated I O �Gj ) , concerning the property located at (��°� S QJ: 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) B) G.W. Elevation 31a +the MAX.High G.W. Adjustment. e DIFFERENCE BETWEEN A and B SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder:cert F��k L°�