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Home My WebLink About0017 TUCKERNUCK ROAD - Health 17 Tuckenuck Road Centerville, Lot 40 A=190-148 No. 42101/3 ORA GO 0 ESSELTE 10% O C O O i / TOWN OF BARN NjSTABLE LOCATION I`1 W L1-r' SEWAGE # m S� VILLAGE ASSESSOR'S MAP & LOT/f 0- I�/ INSTALLER'S NAME&PHONE NO. .�p P n1) SEPTIC TANK CAPACITY l5 LEACHING FACILITY: (type) 2-- 3 t, A ;- X L � NO.OF BEDROOMS 3 BUILDER OR OWNER ` PERMITDATE: I `l 2 i COMPLIANCE DATE: -a. Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r �r 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 n / within 300 feet of leaching facility) /""�'� Feet Furnished by �' . . C G1' No. / :i Fee " .�•' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: J� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for �Digoq;al *p!tem Congtrurtion Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Loc;io Ad¢Egss or Lo No. Owner's Name,A dress Ted.No. 6 , fzv ♦Gwz�vc- •. Assessor's I ap/Parcel=, V,�zQ Installer's Name,Address,and Tel.No. —� Designer's Name,Address and Tel.No. Type of Building: 73 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 Repairs or terations(Answer when ap y able) i7 6 -t — K Date last inspected- Agreement: ��/ . The undersigned ees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance wi a provision e 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed by )i&d olth� Signed Date Application Approved by Date X Application Disapproved for the fdKowing reasons Permit No. —41TE Date Issued TOWN OF BARN TABLE SEWAGE# Lo(krION VILLAGE ASSESSOR'S MAP & LOT 0— INSTALLER'S NAME&PHONE NO. 'v ` SEPTIC:.TANK CAPACITY C✓ v LEACHING FACILITY: (type)` b x (sire) �'/ X '�'�•/ NOOF BEDROOMS .3 BUIIDER.OR OWNER PE MrrDATE: 2 A COMPLIANCE DATE: Separat chi Distance Between the: M Adjusted Groundwater Table and Bottom of Leaching Facility j Feet Piivate Water Supply Well and Leaching Facility (If any wells east on'-site,or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist /c� Z Feet w:itlii' 300 feet of leaching facility) Furnished by qW X t+ F f' �--- No. � '� i+�*+_ ''-,.'"" Fee ��/•, � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes -a PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 0pprication for Migoml *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot�No. ,,, /) 16 Q-�yS' Owner's Name,Address and Tel.No. _ �1 1 T / '1C`!'►L�/ t Assessor's Map/Parcel _ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. r<•� 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 Repairs or Alterations(Answer when ap able) C 6 X 5� Z Date last inspected: Agreement: . The undersigned es to ensure the cons ion and maintenance of the afore described on-site sewage disposal-system in accordance wi a provision , ' e 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed by t is ,oard o�lth� Signed r Date Application Approved by Date Z�� Application Disapproved for the f owing reasons Permit No.9 /0 Date Issued THE COMMONWEALTH OF MASSACHUSETTS ' BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired Upgraded( ) Abandoned( )by &U�4 at � has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector �. V. 1 No. Fee Vo THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS M- gpogaf *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( �4 Up rade( Ab don System located at 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 permit. Date: Approved by 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) S l , hereby certify that the application for disposal works construction permit signed by me dated f `12. z ,concerning the property located at c( �Z:meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility 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. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will Bpi 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) SIGNED:4CSYSTEM D �9�— DATE: LICENSE 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). q:health folder:cert �� r�� ,. .., ... _... � w .. .. j