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Home My WebLink About0058 ELM STREET - Health 58 ELM ST. HYANNIS A = 310 191 TOWN OF BARNSTA i a LOCATION JD$ 41M S �__ SEWAGE # �✓ ZQ� VILLAGE /�l1'��%5 //ASSESSO�RQ'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J16V GAL / y,f LEA-CHING FACILITY: (type) X'.vF lbla✓yd i-Cm (size) NO. OF BEDROOMS BUILDER AD OWNER 4 h ` PERMITDATE: IS COMPLIANCE DATE: 00 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 /�G.L N h ` Q < Ll J a IV Feers THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Oigoml *p5tem Construction Permit Application for a Permit to Construct( )Repair(i/)Upgrade( )Abandon( ) IF Complete System ❑Individual Components `'• Location Address or Lot No. )"'l Owner's Name,Address and Tel.No. � -Assessors Map/Parcel ,ram/iGa��/S AV IV�5Ahlc lievSl� Installer's Name,Address,and Tel.No. l Designer's Name,Address and Tel.No. ,6v�t�Cot�/Caeg>` 77/ -�W Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder("Ar Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow JJ gallons. Plan Date Number of sheets Revision Date Title A 0 Size of Septic Tank Type of S.A.S 9ZY9/4'. 5-1•�r Description of Soil r�,, a 0 "nnF�`�` Nature of Repairs or Alterations(Answer when applicable) H/11-Af. Date last inspected: Agreement: t 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 s Boar of ealth. Signed Date Application Approved b . Date Application Disapproved for the following reasons Permit No. Date Issued TOWN OF BARNSTABLE r l LOCATION SEWAGE # Z VILLAGE /i�/!I'��✓�S `ASSESSOR'S MAP & LOT cl�� INSTALLER'S NAME&PHONE NO. 1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) l!)')y0 X .f NO. OF BEDROOMS BUILDER O OWNER n N PERMIT DATE: 5 COMPLIANCE DATE. Separation Distance Between the: u, Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist PP Y Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within>.300 feet of leaching facility) Feet Furnished by /Sl.l 11 j I_ ,7 No. i LI(V4 '�P+ I _.Fee". .,° THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS s 01pprication for ]Bizpozaf *p.5tem QCongtruction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) YComplete System ❑Individual Components Location Address or Lot No. ® F/ y Owner's Name,Address and Tel.No. Assessor's Map/Parcel /�,l �i /S Allf/✓d14A(_ /*u5/� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1i7///, �S 77� 9�99 { Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Other Type of Building No.No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /M gallons per day. Calculated daily flow 33e gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /S_VZ9 Type of S.A.S. 1,151,41 Description of Soil 1i`/X/q,*/_S Nature of Repairs or Alterations(Answer when applicable) A 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 Boar of Jjealth. Signed Date —`5/15IeV Application Approved b J Date Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS 3jAD'—��/ BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that tl a On-site Sewage Disposal System Constructed( )Repaired((/Upgraded( ) Abandoned( )by d4" 7` (� C S at �7`- 5 has been construcg in accordance with°the provisions of Title 5 and the for Disposal System Construction Pe l -1- �� dated r Installer Designer A 4-- The issuance of this perglit sh)j not be construed as a guarantee that the ytowill f�n�ctio �desig e� Date Inspector / n (;�� ftE____y�_y_ __/______________________________ No. �, �/�'` G� / �� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migoal *p! tem Construction Permit Permission is hereby granted to Construct( )Repair(✓ )Upgrade(, )Abandon( ) r f 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:Cons t must be com eted within three years of the date of thi it. Date: "!O ' 'Rer 6;:05 Approved , �, S y � �� ,, v 5��rd T s� /piX yD�X,S C ��, t �� _.� ® o �S � II �I� yt� ►✓ufer ��a y 'a ,1 u6099' NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH.YD .APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (wTMOUT DESIGNED PLAINS) L ®dP/'T J , �D��d�J, f aer ebv ce:ary that the application `or disnosal w-onks censt,-ucson permit sioned ov me dated concernins he / o property located at S`�/ �` v�7j. j�Qll�/'/S meets ail of-.he eilowina criteria: �1/ ne failed system is cone,ed:e a residential dweilins 3niv. :here are ao :.ommermai or business /uses associated with the dweiling. Y ae soil is ciassined as C aSS _and:he ce=ciatien rate s ess:iian or-QUai :o aunutes ce:Lnca. There are no wetlands within 100 feet of he crcresea seals 37stern here are no private wells within If0:eet of: a crcLlosed seeds system ✓ were s no increase in flow and/or chance n --e cropcsed her e are no variances requested or needed +� The bottom of the proposed leaching°aclity w it:-1ot be located less than five fort above he ma dmum adjusted groundwater table eie raticn. '_Adjust he groundwater able is-Ang l:e r mptcr method when applicable; t✓/ if the S.3.5. will be located with 2d0 reef of sty vegetated wetlands. :he bottom of the :;repose—_ I'eac,hing facility will not be located less than x th uneen(14) feet above the maximum ium adjusted groundwater table elevation Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation -the-W-IC High G.W. Adjustment. - = z DIFFERENCE BE A and B 2-6) SIGNED DATE: �✓?�®� [Sketch proposed plan of system on back]. q:heft folds nett