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Home My WebLink About0055 POPONESSETT ROAD - Health CQar�n�sse� �� • 3 TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS: ��a +� �s�f�i� ' MAP NO. _ PARCEL NO90 ,',, OWNER NAME: 1 ' '�/c� �':�i"•+t't % <,.,t, i, #�5 t'� VILLAGE: Q (J i'k)ii- INSTALLATION DATE: n J' B s ADDRESS: ` r A a CERT. NO. PH 6 tJ 9 I�Ao 1 17/ U-NK I N'O A I ON— LOCATION OF TANK: -"CAPACITY - > TYPE 'f AGE S FUEL/CHEMICAL TESTING CERTIFI-CATION C I PASS C I FAIL DATE LEAK DETECTION CVI CHECK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION C ] YES Cyr]NO DATE TO BE REMOVED 6V3 FIRE DEPT. PERMIT ISSUED C ] YES C I NO DATE CUNSERVAIION C-] CHECK IF N/A DATE -t BOARD OF F HEALTH TAG. NO. C' 7 C 1[ . 7 C ] DATE t fl PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD a 55 Po ks--,t A � TOWN"OF BAkN STABLE LOr'ATION �.,5,- ��' �•" eJ."-{� SEWAGE# 9 7— /2 3 VILLAGE �� ASSESSOR'S MAP & LOT 'INSTALLER'S NAME&PHONE NO. ;T��'''' �' 1 � 4`1 g..9� 9S' SEPTIC TANK CAPACITY js� 4i ) ✓� / �� LEACHING FACILITY: (type �2 v�> (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 7— COMPLIANCE,DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility' Feet Private Water Supply Well and Leaching Facility (If any_;wells just .'.. on site or within 200 feet of leaching facility) 1: 4 � Feet Edge of Wedand and Leaching Facility(If any wetlands exist" µ within 300 feet of leaching facility) 'm z Feet Furnished by �iCk KUI A � Q eA A" p2 7 4A 3 A 35� / f �� A R� TOWN OF BARNSTABLE LOCATION nO ` eS SEWAGE # VILLAG Oo Y ASSESSOR'S MAP &LOT I; OUP INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= LEACHIIN-, FACII.ITY: (type) Cj2S_C�uOtM (S (size) NO.OF BEDROOMS �1 BUILDER OR OWNER C. PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 l�ng facili ) Feet Furnished by ,, �.J c� � `, . 'i �� '� ti s � ' �p � a rn N 0 0 joy 9£.g t o o w +16C 11 R.4' 5 y 10Lh 5 0' Zb ch 195 4c7 16 5" —4W i co-1- 5 � No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zippricatton for 10t5pool *pgtem Con!6tructton Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) [FComplete System ❑Individual Components Location Address or No.VA7 f S-e Ow6'stName,Address and Tel.No. Assessor's Map/Parce/a �a /, /h G(ey !/7��,y�iv. 0 JSs Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. JJGiN �� a A, -a dl/ss viu-t Ski 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 �✓�V 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) 0.4j1ece T ♦� f /7000 ;j r / S Nf�a /r'��Ya lvrs 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 tnto ar of HeaSignedDate Application Approved by _ i / ' Date Application Disapproved for the following reasons Permit No. Date Issued "' dQ Y n� V�.'fie- }' / No. Fee G� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE}MASSACHUSETTS 4 �~ Zlpprication for Migpogaf *pgtem Congtruction Permit Application fora Permit to Construct( )Repair( )Upgrade Abandon( ) ZComplete System ❑Individual Components Location Address or Lot No. �s� Owner's Name,Address and Tel.No. S oh1f$.e Assessor's Ma"p/P"ar eE 1 �.d /� v/h�� G Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3?O gallons per day. Calculated daily flow _ gallons. Plan Date Number of sheets Revision Date. Title i Size of Septic Tank Type of S.A.S. j Description of Soil I Nature of Repairs or Alterations(Answer when applicable) 6s c �i�S l / tJl� s! 7�-/a�r /�DaC4 brsI� Date last inspected: i 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 t ' az of Hea h. Signed Date Application Approved by 'Date Application Disapproved for the following reasons ' Permit No. Date Issued�'°� ,` � ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Y Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed{ ) Repaired (�Upgraded•(4 Abandoned( )by �"�' p, �af� at 7y has been constructed in accordanc with the provdiods of Title 5 and the for Disposal System Construction Permit No.117,✓ dated Installer Designer The issuance of this permit shall not be construedas a guarantee that the system will function as designed. Date - !/ Inspector--------------- Jet l � r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligpogal *pgtem Congtruction Permit Permission is hereby granted to Co truct( )Repair( )Ujagrade(✓)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. i i Provided: Construction must be completed withinthree years of the date of thiisss nwit. Date: � f �� / Approved 1 TOWN OF BARNSTABLE LOCATION ' ' ' ' s SEWAGE # 7— /2 3 ��' �-+ ASSESSOR'S MAP & LOT VILLAGE C U;STALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �S�U i LEACHING FACII.TTY: (type) l' f"I ti'' (size) `!� X �'/>>� NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: -� 7_ COMPLIANCE DATE: I / Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Pr1vate Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by a r3738 � G r 3 A Lt NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only I CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANSI I, >JO),?� � u!/� , hereby certify that the application for disposal works construction permit signed by me dated 3 /? 9, , concerning the property located at SS o vh� fs meets all of the following criteria: v stem There are no wetlands within 300 feet of the proposed septics y There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility r/ There is no increase in flow and/or change in use proposed There are no variances requested or needed. SIGNED DATE: LICENSED PTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER h Ian of the proposed system.Also if the licensed installer posesses a certified plot plan, [Attach a sketch p p p y this plan should be submitted]. j:ccrt '� .- . �'°��..� --_ Q V�� 6 �� 0� �� 4 O !i I t i y I n �