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HomeMy WebLinkAbout0115 THIRD AVENUE (HYANNIS) - Health 115 THIRD AVE HYANNIS A= 245 120 A i TOWN OF BARNSTABLE LOCATION l � J� SEWAGE # '� s� VILLAGE /ASSESSOR'S MAP &LOT `INSTALLER'S NAME&PHONE NO. �0�7zOGodf`� CQ� 77/` 3�� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT-DATE: 2l / COMPLIANCE DATE: Z Lod 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 7 i W I .4 v) i TOWN OF BARNSTABLE LOCATION 414'le SEWAGE # VILLAGE �rIIsDDi r ll ASSESSOR'S MAP & LOT Z 4 5-12-51 INSTALLER'S NAME&PHONE NO. 7`000I, 11 e2`10 T71- SEPTIC TANK CAPACITY L ` LEACHING FACELITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER �}PqC�� PERMITDATE: � Z. — / 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 Facifity(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t E is c fir, r� L, 1 Lz 4 _ o No. �/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Miopozat *pgtem Couo/tructiou Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) L�J Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Asses l- /Zk� IV , Installer's N ne,Address and Tel.No. Designer's Name,Address and Tel.No. flO�t�O Z�� " 7 7/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(11�� Other Type of Building 5 4 Ao.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow I/d gallons per day. Calculated daily flow gallons. " —Plan Date Number of sheets Revision Date Title Size of Septic Tank / Q Type of S.A.S. /Z sS^X Z✓�XZ. Description of Soil 2 —5W0,01lee elS Nature of Repairs or Alterations(Answer when applicable) 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 his o of alth. ` Signed Date Application Approved by Date 'Vol Application Disapproved for the following reasons Permit No. Date Issued $" C No. 7 Fee J �✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION 2 TOWN OF BARNSTABLEs MASSACHUSETTS ZippYication for Migaal *pgtem Conotruction Permit Application fora Permit to Construct( )Repair(fel)Upgrade( )Abandon( ) k Complete System ❑Individual Components 'Location Address or Lot No'. Owner's Name,Address and Tel No. )!s` r`�ir a� berme Assessor's r apI'k� IV , t �/ Installer's 1�pe;.Address and Tel No. Designer's Name,Address and Tel.No. w* Type of Building: O Dwelling, No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder «No.of Persons Showers( ) Cafeteria( Other Type of Buildingw;�5 ) 'Other Fixtures Lesig9LFlow. 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 applicable) Date last inspected: Agreement:--- V 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?,j. ofYkalth. / Signed Date 7/zJ/� ARplication Approved b" r Application Disapproved for the following reasons , Permit No. Date Issued — A ' THE COMMONWEALTH OF MASSACHUSETTS Z ✓r`� BARNSTABLE, MASSACHUSETTS w (Certificate of (Compliance , THIS IS TO CERWFY,that the On-site Sewajr Disposal System Constructed( )Repaired (✓'Upgraded( ) Abandoned( )by D % C D115 at _ ;/ O Lt/, ' s , 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 pe M A shall not be construed as a guarantee that thereilfunction s dg�'ned� Date � Inspector _-- - - _ --- - - - --- - - No. % Z 115 Z© Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Mwioonl *pgtem Con!6truction Permit Permission is hereby,granted to Construct(/)Repair(✓)Upgrade( )Abandon( ) 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 th' ermit. :Date °�'' Approved I, - 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 PERINUT(WITHOUT DESIGNED PLANS) I, J - hereby certify that the application for disposal works construction permit signed by me dated 7/Z 7/�� , concerning the property located at /f Jr— IJra��rr / j�?'/l/P%S�/y"meets all of the following criteria: F/ The failed system is cone-ed to a residential dwelling only. There are no commercial or business ZTh es associated with the dwelling. e soil is classified as CLASS I and the percolation rate is less an or equal to o minutes per inch. "/ There are no wetlands within 100 feet of the proposed septic system Y There are no private wells within 1-40 feet of the proposed septic system Therei n w / s o increase to flow and/or change to use proposed " There are no variances requested or needed W The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted ou.ndwater 1 l d' the groundwater table elevation. [Adjust o dater table using the Frimptor J � � J � g _ ethod 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 Iocated less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: 9 A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX High G.W. Adjustment. DIFFERENCE BETWEEN"A and B Z-Z! 1 SIGNED : DATE: �! Z/-4py- (Sketch proposed plan of system on back]. q:health folds cat w O OO 1 7-7-116( /fi ll-