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Home My WebLink About0022 OLD SCHOOL HOUSE RD - Health 22 OLD,SCHOOLIIOUSE RD. HYANNIS A = 268 113 (IJQ 7 d 1 No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippricatfou for Mtootal 6potem Cow5truction Permit Application for a Permit to Construct( )Repair( )Upgrade(��Abandon( ) O Complete System ❑Individual Components Location Addres or Lot,No. JJ n Owner's Name,Address and Tel.No. 02� O/ S ,,ooj �/vvsF 12 /.�G�i2 I'A '4 Assessor's Map/Parcel A/X a.r/AS Pv,'L T . Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /� R c� Cs ,✓4'T ('o 3 G e of Building: �'P g Dwelling No.of Bedrooms -01 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 O Z--9 Type of S.A.S. L /� �✓� �- Description of Soil; Nature of Repairs or Alterations(Answer when applicable) �T�e !Soo 74 .v y f30� C 0 © �! X �/ 7 /1 E ,�� l v 2 6 3 a X 02 X y 7-G2 vc <s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of afore described on-site sewage disposal system in accordance with the provisions of le 5 of the Environm al Cod "I to e e system in operation until a Certifi- cate of Compliance has been is oard of- th. Signed su Date d Application Approved b Date l s d Application Disapprove or the following reasons Permit No. Date Issued (� TOWN OF BARNSTABLE Wolf LOCATION/� 6IS Sc-4 00 I Li ®v5� �� SEWAGE # ��e� G o5% VILLAGE f'' A'v�✓f11 Pf-2 i ASSESSOR'S MAP & LOT9 "' .-/ INSTALLER'S NAME&PHONE NO. .�%y�A-C SEPTIC TANK CAPACITY C S O O C14 LEACHING FACILITY: (type) /�� f�Q E (size) X 5-" NO.OF BEDROOMS BUILDER OR OWNER _/� � �i �,� ��`�� P ty �✓ PERMITDATE: / /S- ��a 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 � 1 �i b C i Cr' o � � o © S �, No. Lam.�� L/D / Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS e `113 01pphration for Xkgooar *potem Con.5tructton Vernrif Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Addres or Lot o. Owner's Name,Address and Tel.No. Z o/ S� ou a..sE 2 /�c�.ei.�-v /-1ovS A 70�✓ ' Assessor's Map/Parcel X,0.vim/ Q 7— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. R GN Ko *,mr r (—d 3 G Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder V� 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 Dote Title Size of Septic Tank / JS � 9 /�e., Type of S.A.S. E A < Description of Soil Nature of Repairs or Alterations(Answer when applicable) %i roc / S a v i ,y L) a,k Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance oft e afore described on-site sewage disposal system in accordance with the provisions of T' le 5 of the Environnapnfal Code. t toyjaS5Ae system in operation until a Certifi- cate of Compliance has been issu s-Bo rd of 1jealth. Signed Date c'X c ,a Application Approved by.- Date. 2 u cam? i Application Disapproved or the ollowiiig reasons Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certiftcate of Comphance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by /4)2 C A/ Go,-57- 7) " i 3 6 Z at .P,a. o�G� S^c Al 7-has been constructed in accordance � with the provisions of Title 5 and the for Disposal System Construction Permit No. dated/A- Installer I si /2 ---f-1 (-,—,,- ;— Designer The issuance of this permit shall not be construed as a guarantee that the s s m>will function as esigne-d. Date �/ --��1'� Inspect ..: ( —r ------------------------------------ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS 'Wf 5pogal *pgtem Con.5truchon Vermtt Permission is hereby granted to Construct( )Repair( )Upgrade(!/)Abandon( ) System located at a o S� d o�s r /?4L� ""XV a,1.1 J" 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,.pefmit,. Date: /r f 1l �Z�� Approved by' � = r f" a 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. t CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL z WORKS CONSTRUCTION PERMIT WITHOUT DESIGNED PLANS hereby certify that the application for disposal works construction permit signed by me dated l 5�Zo v , concerning the property located at 0 �ooZ-410v s f "'24�17 meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ,.---�Tle.re are no wetlands within 100 feet of the proposed septic system .. here 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. �he bottom of the proposed leaching facility will not be located less than five feet above the maximum 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) e2 S B) G.W. Elevation _ +the MAX. High G.W. Adjustment. DIFFERENCE BETWEEN A and B ; SIGNED . DATE: /-V o 0 [Please Sketch peposed plan of system on back]. NOTICE l Based upon the above information, a repair permit will be issued for vZ bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert TOWN OF BARNSTABLE ((�� O� 1 I SEWAGE # LOCATION:;• o lc% Sc. � co� 1 G� VILLAGE -�y.a"�'✓r 1 � i ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. AC: �-/ SEPTIC TANK CAPACITY Lf`4 LEACHING FACIL=: (type) Gam-/� c A. %,2 t„,c L (size) �� X y � NO.OF BEDROOMS BUILDER OR OWNER /`� r•��2 . ,� ��v �' ,✓ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland 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 i �Q P 3 � G r