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Home My WebLink About0015 BAXTER ROAD - Health .,15 BAXTER�RD,-HY;A�NNIS, � �,�; °'r ,.. � s-- - --- ---- - -- --- - - ---------- -- ---- _- --- -- - --. -,- -_ _ ____ - _ _._ . — - •°' 0 — - -- - � �. a � i e a < . o J (J TOWN OF BARNSTABLE LOCATION %:-� _�`•��. e_r" d SEWAGE # / VILLAGE,.��0.✓ L ASSESSOR'S MAP&LOT-341'Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY.- Z-S 0 O r LEACHING FACIL=: (type) ti L7`� T (�(size) j!Y � J NO.OF BEDROOMS OR OWNER PERMPTDATE: �'~��` 7 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) Feet' Furnished by %�6/AL �st° .I" ��`• �� .. �Y S\lam '� i 1 w J � A'e q�21 �No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pp1tratton for �Dtgaal *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Nomplete System O Individual Components Location Address or Lot No. �(�t Owner's Name,Address and Tel.No. Assessor's Map/Parcel :I f O 0 1 0 0411kNW 4e� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. o-coevgsec,,� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures c' Design Flow —7373 gallons per day. Calculated daily flow "�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. e Description of Soil Nature of Repairs or Alterations(Answer when applicable) AV cC CQ 06-rVI4L Lt 1 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 E ronmental Code and not to place the system in operation until a Certifi- cate of Compliance h en-issued by this SignedV'2�O4 ' Date Application Approved by Date Application Disapproved for the f lowing reasons Permit No. Date Issued (101111 RP q Noy Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH. DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS -=01-ppficat ofilor �Digponl *pgtem Construction, Perm-it- Application for a Permit to Construct( )Repair( )Upgrade( )Abandon omplete System El Individual Components, Location Address or Lot No.` ,( Owner's Name,Address and Tel.No. t" Assessor's Map/Parcel 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 gallons per day.'Calculated daily flow gallons. Plan Date Number of sheets Revision Date 1 Title ' Size of Septic Tank 51 A(A- Type of S.A.S. 6 to � Description of Soil 1 5&A &AO f Nature of Repairs or Alterations(Answer when applicable) � VC G U ML•,:"! 1. J� If C4i:i✓ f ` 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 TW ronmental Code and not wplace the system in operation until a Certifi- cate of Compliance ha eeAissuetrh. SigneV4J Date lv— `. Application Approved by / Date ' Application Disapproved owing are Permit No. Date Issued (10 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance -THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired ( )Upgraded(1/j Abandoned( )by 'I U 4 F S- at S t C. — k1 ( ha constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No, dated Installer Designer The issuanc "f this permit shall n e rtrued as a guarantee that th a will function a esigned Date /fir' Inspec or. t s Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ;0tgpoga1 *.pOtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( Abandon( ) System located at �s 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: Con tru lion ust be completed within three years of the date of t •p t. P G Date: Approved by t� i ' 1161" 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) hereby certify that the application for disposal works // P construction permit signed by me dated [9 ��`�L , concerning the property located at `� (:�L9 meets all of the Mowing criteria: v• The failed system is connected to a residential dwellingonly. There ar y e no comnerctai or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than ore equal to 5 minutes per inch q ere 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 ro sed " • There are no variances requested or needed. The bottom of the proposed leaching p Po g facility will not be located less than five feet above the ma.,dmum 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) lJ` ' B) G.W.Elevation 50 +the MAX. High G.W. Adjustment DIFFERENCE BETWEEN A d B SIGNED : DATE: (% (Sketch propos plan of cyst on back]. q:health folds:art �;� ., � - �.; , . � , � � �'�— oo M �� ` a f