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Home My WebLink About0878 SHOOTFLYING HILL RD - Health (2) 878 SHOOTFLYING HILL RD. , CENTERVILLE A=192-045 111! S//rig UPC 12543 No. OR HASTINGS, MN TOWN OF BARNSTABLE LOCATION y (A vn , ` (Zd SEWAGE # '- Y (o VILLAGE C&^-kr rrttASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SCU �1 fA 7 73 YJ fl SEPTIC TANK CAPACITY k Q0 Q-C- L 0(20 K LEACHING FACILITY: (type) 2 (''1G.xt �L�kv.L (size) NO.OF BEDROOMS BUILDER OR OWNER�,!, ,Q L PERMTTDATE:��I ( S � 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) . 010 Feet Edge of Wetland and Leaching Facility(If any wetlands exist A l� O within 300 feet of leaching facility) �\/ / Feet Furnished by r -ko S� 1 (3-o SA c A-v ® 'vX (,O f A A-0 '7 7 �kv`T.n�•.�. 7� a a Qvl ' �v No. FEE �— �f. a COMMONWEALTH OF MASSACHUSETTS Board of Health, (;,� -�- , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) R� air( ) Upgrade( ) Abandon( ) - ❑Complete System O Individual Components Location S�' tJ ` �. ' ( ,, .. Owner's Name Map/Parcel# Address �oa Lot# Telephone# Installer's Name ( Designer's Name Address �� ' -� �� Address Telephone# 5�,� '��'Q Telephone# Type of Building Lot Size sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) '3 3 gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation D SCRIPTION OF REPAIRS OR ALTERATIONS 4 0�0 &CAS- tU_A-V jc The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agues to not to place the system in operation until a Certificate of o tfiianc has been issued by the Board of Health. Signed Date sId, .� z- TOWN OF BARNSTABLE LOCATION _U x S OS �1v��15 lay 11 CZ� SEWAGE # VILLAGE C AA.Ar-r�,k\LP ASSESSOR'S MAP & LOT - G1 L/�5 INSTALLER'S NAME &PHONE NO. SCCU J� (''�� nIl"��,��1,( 7 73,K)i fj SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Nl1.xt ^�rl lu (size) —CJ Q NO. OF BEDROOMS :�S BUILDER OR OWNER rr- .o L `x-Uepp 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(If any wetlands exist within 300 feet of leaching facility) JO^'Q Feet Furnished by -�O Q Ap SA C A-0 O Qox ('O� A-E6 OC3ax °17 C 4.6, a � �v _Y No. FEE S COMMONW[ALA-rF �MASSACHUSETTS rr Board of Health, `�C� r\-1��QLE � a , 1VIfI. APPLICATION FOP, DISPOSAL. SYSTE, l[ CONSTRUCTION PERMIT 4 I Application for a Permit to Construct( ) Repair(_), Upgrade( Abandon( - ❑Complete System ❑Individual Components Location v ( ^111 Owner's Name C-C„ OX K nee jpfO Map/Parcel# O ;k ! Address / U ' Lot# JF Telephone# Installer's Name M Designer's Name Address 1<4 t J V�� \ ut�1 S Address Telephone# Telephone# J Type of Building Lot Size sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder jv' Other-Type of Building No.of persons .Showers ( ),Cafeteria ( ) � _ t Other Fixtures Design Flow (min.required) 3 3 gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation � ry l 7 DESCRIPTION OF REPAIRS OR ALTERATIONS ` � \C.�C-. C C' C Pc L) The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es to not to place the system in operation until a Certificate of om iaancg has been issued by the Board of Health. Signed_g1 -. Date (d, No. / - COMMONWEALTH OF MASSA'l_HUSETTS FEE � Board of Health, bb� _ , MA. CERTIF ICTE Of COMPLIANCE Description of Work: ❑ System Individual Component(s) U''Com Complete S tem P The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (Upgraded ( ),Abandoned ( ) by: CG.r \4-u C2 e ` has been installed in accordance with the provisions oUJO CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. , dated 7~?/`9 Approved Design Flow 3 (gpd) Installer � t^{�,VL.- Designer: Inspector: Date: F i ! V The issuance of this permit shall not be construed as a guarantee thaw / - V { `� p gu h�t�he system will function as designed. No. / r— FEE C®MMONWLALT14 Of MASSAC14USETTS Board of Health, �e,,f f\1-,VW- , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(V Upgrade( ) Abandon( ) an individual sewage disposal system at SC"�Z�C��C �` 1 � sZ� as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All llolllooccal conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 7 Z -g0 Board of Health J��L�c �IVJ�/ !/ _. — 10/9/97 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) i I eby certify that,the application for disposal works construction permit signed by me dated LQ cl , concerning the i property located at �� --meets all of the i following criteria: ' There are no wetlands located within 100 feet of the proposed leaching facility / l/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 fThere are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any 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 Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map),3-43 SIGNED : DATE: h I LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER � r (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:cert Q