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Home My WebLink About0028 PATRIOT WAY - Health 1. 28 PATRIOTS WAY, CENTERVILLE A= 192-129 No. 42101/3 ORA ESSELTE 10% ti . 0 0 0 0 TOWN OF BARNSTABLE 79 LOCATION �� C w d + SEWAGE # VILLAGE S- ASSESSO_R'S MAP&LOT l� . 9 'I INSTALLER'S NAME&PHONE NO. �o Jl t� C"r� 7Z—v t SEPTIC TANK CAPACITY /00o LPL 13C)c 0Id 1 � LEACHING FACILITY: (type) (size) VrJAR,_ NO.OF BEDROOMS etr C) /y T�L� ( V � BUILDER OR OWNER C PERMITDATE: - k/96 COMPLIAN E DATE- Separation Distance Between the: OLWMaximum Adjusted Groundwater Table and Bottom of Leaching Facility ' Feet Private Water Supply Well and Leaching Facility (If any wells exist �g on site or within 200 feet of leaching facility) �v Feet Edge of Wetland and Leaching Facili any wetlands exist n, within 300 feet qSleachin i i 0 Feet Furnished by A Ao s� A- co VA DS kia o x -0 t 6/7 ri Pik � \ Am k5-� 7,,,C LO ASSESSORS MAP Na,...rL,_______ No. •.` Fee THE COMMONWEA�LTH�OF��SET�TS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mizpozar *pgtent Construction Vertnit Application is hereby made for a Permit to Construct( )or Repair(✓)an On-site Sewage Disposal System at: Location Address or Lot No. A v 3 Owner's Name,Address and Tel.No. A 6Av-i Installer's Name,Address,and Tel.No. �� S� / Designer's Name,Address and Tel.No. rz_—��Ik v\ 04 1p�QA Type of Building: 13 Dwelling No.of Bedrooms 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 Description of Soil Nature of Repairs or Alter tions(Answer when applicable)��.��« «:�urls y,.) o� 'f r-e- -' [ --der- Ab `5 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 EnvironnitataLCade and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of ealt Signed Date b Application Approved by Application Disapproved for the following reasons Permit No. Date Issued �� ' ♦ r f No. /d� Fee rt THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS t 01ppYication for Digpogal *pgtem Construction Permit i Application is hereby made for a Permit to Construct or Repair V an On-site Sewa a Disposal System at: PP Y , ( ) P ( ) g P Y Location Address or Lot No. A 3 Owner's Name,Address and Tel.No. at �..x�� Installer's Name,Address,and Tel.No. 7� �� Designer's Name,Address and Tel.No. Type of Building: i Dwelling No.of Bedrooms Garbage Grinderk Other Type of Building No.of Persons Showers( ) Cafeteria( ) f Other Fixtures I Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil !� Nature of Repairs or Alter tions(Answer when applicable) /h` �rn«` �-"�UC S �,) (r( �'} OC ji, % Ono 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 Environ Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of i —ealth Signed Date /r/ Application Approved by r Application Disapproved for the following reasons Permit No. ''/ Date Issued —7 --------------------------------------- r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS.,— Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( /)on by !&Q>� l- r,..l.(� for c.� < c. tJc \ as been constructed in accordance�- with the provisions of Title 5 and a for Disposal System Construction Permit N dated- 145e- ' , 'r Use of this system is conditioned on compliance with the provisions set orth elow: No. �<" Fee. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migoar *pztem Conetructton Permit Permission is hereby granted o to construct( )repair(t/)an On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to s comply with Title 5 and the following local provisions or special conditions. All construction must betcompleted within two years of the date below. (� Date: ,/ A roved r PP Y. t. CEItTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS'I'KUC7'ION 1'E1tM1"l' (1V1'1'IIOUI' DESIGNED PLANS) � j�hereby certify that the application for disposal works construction permit signed by me dated ) �f ! c1 w , concerning the property located at Pli�c�i d� W�-� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility, • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: lk I LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAttach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submittcdl. x Ilk- L2HEALTHDEPT, WE CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT 1875 ROUTE 28 [Q02CENTERVILLE, MA 02632 (508)790-2380/FAX#(508)790-2385 RNSTABLE .OIUHAZARDOUS MATERIAL RELEASE FORM F-A.# 4v LOCATION: ADDRESS OF RELEASE:__ DATE OF RELEA E^. =i PRODUCT RELEASED'- ESTIMATED QUANTITY: CORRECTIVE ACTION TAKEN-BY RBSPOWSIlkk4ARTY: NOTIFICATIONS: FIRE DEPARTMENT: YES1 ) NO( ) DATE: TIME: E. NATIONAL RESPONSE CENTER YES( ) NO( ) DATE: TIME: DEPT. OF ENVIRONMENTAL PROTECTION YES( ) NO( ) DATE: TIME: OIL SPILL COORDINATOR: YES( ) NO( j DATE: TIME: TOWN BOARD OF HEALTH: YES( ) NO( ) DATE: TIME: TOWN HARBORMASTER: YES( ) NO( ) DATE: TIME: " OTHER AGENCIES: COMMENTS: %- _ . . ►_i t �___. . •.,,.• r l •.+r.-. {J >,.IlV ! .t I L♦ . • w ♦ v I+• V r -+✓ J/ !f a .1 Z-e ry .� �_s�.+ 1 i I.G f`✓ • v. " r V♦A,/� •(„J • 1 >c:,. Y 4. ♦ . . .. e\ • . V, ..! V .' - ' I tJ r♦. i �f✓!T 3 1 1 1G t. i,.rd 11J !V♦_. �, . I..r -c..!r V I� v r C '1.. V ♦ v.1./.`.•..•• v G- v., C...' er V�♦.../ r ..,�✓, ! t . ! 1 V l.t.c.W 4— ,—11 r Cis t•.,/•i/ {...! r Cp• X . —1 . r, . 7_' 1�+.•! `.l./ +.r r.l..••4� (.. (J!✓ ! LJ lJ'4.. ...� I 1 J I REPORTED BY: t , n i 1! DATE: r` " A ".a-) v V I''�� N 1 -- WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.I .P. PINK COPY-BOARD OF HEALTH C-0-MV, FORM#58 CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT 1875 ROUTE 28 CENTERVILLE, MA 02632 (508)790-23801FAX#(508)790-2385 OIL/HAZARDOUS MATERIAL RELEASE FORM F.A.# 03 5 q LOCATION: ADDRESS OF RELEASE: --*f 6 P+gT'e_ 1 o-'5 ooA DATE OF RELEASE: 0 Zw 2coo2 PRODUCT RELEASED: ESTIMATED QUANTITY: l CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY: NOTIFICATIONS: FIRE DEPARTMENT: YE ) NO( ) DATE: TIME: NATIONAL RESPONSE CENTER YES( ) NO( ) DATE: TIME: DEPT. OF ENVIRONMENTAL PROTECTION YES( } NO( ) DATE: TIME: OIL SPILL COORDINATOR: YES( ) NO( ) DATE: TIME: TOWN BOARD OF HEALTH: YES( ) NO( ) DATE: TIME: TOWN HARBORMASTER: YES( ) NO( ) DATE: TIME: OTHER AGENCIES: COMMENTS: -?A';&2-r`J ct"j ` 9;A.-Am_r_-s ware 5`f"or2-d i:u ve-k;cl-,— LQ h f C,In H+ - i Q ®-r q L P 20 Q b GT _-5Q; )IeQj . AL5 S `t-l,.o_62 G ( l c9&2 l a `t Q. )r e�P 1-t e /- G REPORTED BY: DATE: WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF H LT C-O-MM FORM#58 IV VV