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Home My WebLink About0081 STRAWBERRY HILL ROAD - Health 81 STRAWBERRY HILL RD.,CENTERV. A= s k �J4aFcrttFaco- S /M UPC 12543 Now 553LOR HASTINGS. MN I W/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, J&efT i, �d/*O� /^, hereby certify that the application for disposal works construction permit signed b me dated ,3/Z 7` , concerning the cons p g Y property located at g0 �J�yd'��r �" meets all of the P Y following criteria: 1/ There are no wetlands located within too feet of the proposed leaching facility ere are no private wells within 150 reet of rhe proposed septic system ere is no increase in flow and/or change in use proposed ere are no variances requested or needed. If the proposed leaching faciiity wiil 'e Iocatea-.vithin =`0 reef of any wetlands. the bottom of:he proposed leaching faciiity will =be :ocated'ess:ha.n rourteett i,i tl 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) DATE: SIGNED: LICENSED SEPTIC SYSTEM INSTALLER IN THE 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]. ¢ketch Folder eat rµ¢ (y 7� �vsyCu h� v tY �e 00 �� g Jl Ifp _ ,0000�e �� vx oi 7 .q No. ;?#94f ! .-1 Fee 3- 7a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for -igpogal *pgtem Congtruction Vermit Application for a Permit to Construct( )Repair(`//)Upgrade( )Abandon( ) VComplete System O Individual Components Location Address or Lot No. ;/ /��r,,��//� Owner's Name,Address and Tel.No. Assessor's Map/Parcel 17�„ it vll+//e Rime?,m� Z0r 1w, Installer's Name,Address,and Tel.No. / 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 1/4,2 gallons per day. Calculated daily flow ,aJ�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �,5`®D 99� Type of S.A.S. Description of Soil 2X 3 ZX 7— Nature of Repairs or Alterations(Answer when applicable) ��Tle 40 GC�y/� /2 ,af/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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo d of=alth. j Signed Date �! Application Approved by Dates-�Gy . Application Disapproved for the following reasons Permit No. Date Issued 119 g TOWN OF BARN LE LOCATION SEWAGE # ��'�9 VILLAGE_;<s<:" G'ert �^�//�Iw ASSESSOR'S MAP& LOT INSTALLER'S'NAME&PHONE NO. ) /';I .77/ - Q� SEPTIC TANK CAPACITY 0 i LEACHING:FACII.IT'Y: (type) (sine)9 A,?.? 2 NO.OF BEDROOMS 3 BUILDER OR;O'WNER Zd�hA' PERMTTDATE:_ COMPLIANCE DATE: �b. 9 Separation Distance Between the: Maximum Adjusted:Groundwater Table and Bottom of Leachin Facili -� Private WaterSupply Well and LeachingFacility g ty Feet ty (If any wells exist on site or.:wtYun 200 feet of leaching facility) Edge of Wetland:ad Leaching Facility(If any wetlands exist Feet within 3W.'fopfof leaching facility) . � Furnished Feet I No. °� / /L r FeeL�- +V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION - TOWNOF BARNSTABLE, MASSACHUSETTS pplication for M!6pogal 6pmem Congtruction Vermit FJ) Application for a Permit to Construct( )Repair(>_/i Upgpde( )Abandon.( ) Complete System O Individual Components Location Address or Lot No. 5�t.la�1�► Owner's Name,Address and Tel.No. Assessor's Map/Parcel C, gv&e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(_e_;?1 Other Type of Building G�ileeo No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow .3 31�9 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ;OW Type of S.A.S. 41—lVeX1�012'G'/$ r Description of Soil may. Nature of Repairs or Alterations (Answer when applicable) / I l-/7� G/ 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 been issued this Bo dofl4ealth. / Signed Date !1 Z71f? Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued' ——————————————————————————— ——/————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER IFY,that t)e On-site Sewage Disposal System Constructed ( )Repaired(!� ) Upgraded( ) Abandoned( )by O/_ at JG 7`/ Gv �I'/r / �9h//f� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N + dated Installer Designer IF The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date r) Inspector s 4C~= --------------------------------------- 19 No. G7 / } !/` ✓,�iqe Fee 12 40-4i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mifspogal 6p5tem Cottgtruction Vermit Permission is hereby granted to Construct(/ )Repair(1/)Upgrade( )Abandon( ) System located at �/ $J` -A'G✓,f,elIlly 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 completed within three years of the date of this it. r� Date: �O�Approved by ,� /' P TOWN OF BARNST LE LOCATION Sl tr�p�/d i SEWAGE # VILLAGE Gen /"� E' ASSESSOR'S MAP & LOT Zy� INSTALLER'S NAME&PHONE NO. AO0TOL®1� -- f Z;:90 SEPTIC TANK CAPACITY /37J0 Gv,L/ II LEACHING FACILITY: (type) L�ia/bi t cv) (size) 9 3'2 NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: 3"3O` '� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facilityf Feet Private Water Supply Well and Leaching Facility (If any wells exist 'I/ on site or within 200 feet of leaching facility) /!/� Feet Edge of Wetland and Leaching Facility(If any wetlands exist �J/ within 300 feet of leaching facility) ,�" �" Feet Furnished by a�4�