HomeMy WebLinkAbout0077 HIGHLAND AVENUE - Health 77 Highland Avenue
A= 020- 050
Cotuit
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes
01pphCation for Ditpotal *pmem Con.5truction Vermtt
Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. '7 Owner's Name,Address and Tel.N
Assessor's Map/Parcel citzx. � Q,� 071
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Installer's Name,Address,and Tel.No! �� o Designer's Ame,Address and Tel.No.
yet
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 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 is d by this Board of Health.
Signed Date
Application Approved by Date r1
Application Disapproved for the folio ng reasons
Permit No. Date Issued
TOWN OF BARNSTABLE
LOCATION SEWAGE # 'O
VILLAGE. ASSESSOR'S MAP.& LOT J
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) )
:
X�� ize
NO.OF BEDROOM_
BU
ILDER O OWNER
PERMITDATE: U-13 `IY COMPLIANCE DATE: �1 . L7 _ 9(
Separation Distance Between the:
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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
f Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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No. Fir 2S 7 Fee "5_e�p
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pphration for Migoal *pgtem Congtructton pernttt, ,
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. � Owner's Name,Address and Tel.N •�S
Assessor's Map/Parcel 6Q6 3
I
In 's Name,A dress,and Tel.N ._^ 3 Designer's Pfame,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
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: " }
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 opefation until a Certifi-
cate of 6ompliance has been ' d b 'this Board f Health. *1'
Signed Date * Z
Application-Approved'by Date .
Application Disapproved for the following reasons.
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS b
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO C IFY that the On-site Sewage Dispo§al System Constru ted( )Repaired(V ) Upgraded( )
Abandoned )by .
at 4 has been constructed in accordance
with the ions itle 5 and the for Disposal Sy teem Con truction Permit N',. ��dated
Installerv' L •Designer
The issuance this permit,s4all nit lZe, n�kp as a guarantee that the system 1 function as designed.
Date ' �- Inspector
J THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
i� ogar �pgterrY��ongtructton Vermit
Permission is hereb ranted t Con truct( )Re ")Upgra e�( Abando ( )
Sys m located , AA
d
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 t s permit.
Date: — aJ`0 Approved by
l019/97
1
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
TION OF SKETCH AND APPLICATION ION FOR A i
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated 'a�J concerning the
property located at zMJ&A4 meets all of the
ml4d
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facilityThere are no private wells within ISO feet of the proposed septic system
(/• There is no increase in flow and/or change in use proposed
6,41 There are no variances requested or needed.
,41 If the proposed leaching facility will be located within 250 feet of any 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 Elevation(according to the Engineering Division G.I.S.map) '
� t0
B)Observed Groundwater Table Elevation(according to Health Division well map) Vrr�L
SIGNED: 171A0---*3DATE: 111A,:?)h
LICENSED SEPTIC SYSTEM 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:cett