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Home My WebLink About0104 FOURTH AVENUE (HYANNIS) - Health 104 FOURTH AVE.`,HYANNIS --- — — — — . i o o � o No. Coo Fee C�Z THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for ]Dtopogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( . )Abandon( ) O Complete System F1 Individual Components Location Address or Lot No. 'b a v 2 Iv Owner's— v�Naym�e,Address and Tel.Nrto.t /� Assessor's Map/Parcel � t W Y (`, ( ,I 7—A-CU Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. M1 A-C-6(e—Sc(,o L 0 v Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �1 .� /t Design Flow ! ` b gallons per day. Calculated daily flow f67 gallons. Plan Date Number of sheets Revision Date • Title Size of Septic Tank t �CO Sear r i C—`V Aw4 . Type of S.A.S. /4 Cr c;4;�;==P*l� Description of Soil rJ nme� 0D cve6:iA Nature of Repairs or Alterations(Answer when applicable) T—I9•�(� /�f STr �.kzzy J c7 S j �I J t C"`SZ_• LJVt� J/.Qr 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 oard alth. Signed Date Application Approved by Date =f � Application Disapproved for t;b1lowin reasons Permit No. 'o4in5, Date Issued TOWN OF BARNSTABLE LOCATION Al2 Fau�dz A! SEWAGE/� - I : VILLAGE J-A1dx1,,e11 b�/j�_ASSESSOR'S MAP & LOT Y INSTALLER'S NAME&PHONE NO. /Y7i/�C4a& SEPTIC TANK CAPACITY o LEACHING FACILITY: (ty ) (size) X90 NO.OF BEDROOMS j BUILDER OR OWNE i PERMUDATE: DD �COW�LIAN�CEATE: 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 leaching facility) Feet Furnished by .........- .. ....... .. .. o�,z G - N. L7 d - :) No. '.µ.i: a..,i t - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: , ' Yes PUBLIC HEALTH,DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01poYication for Miopota �pgtetn Congtructiori ertnit ' Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Y f `� Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No- /M, C� �cd C_ i Type of uh ing: ' Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures _ Design Flow 1-i t/ gallons per day. Calculated daily flow It/ gallons. Plan Date Number of sheets Revision 15ate Title -� Size of Septic Tank r _ Type of S.A.S. t Cyr d-- � Description of Soil w Nature of Repairs or Alterations(Answer when applicable) ar- v Mcw 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 Board of Health. i igned i Date Application Approved by Date ,r Application Disapproved for th owt reason ` L t, Permit No. Date Issued ——————————————————————————————————————THE COMMONWEALTH OF MASSACHUSETTS ( , }BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(� Abandoned( )by at has been constructed in accordance with the provisions of Ti e Sand a for Disp sa ystem 'ons ction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the ,y t m will function as c�s'gned.a G Date II Inspector e. A 1(// //il Ad/ A �Pl/ L _ Yo %T U d No. O _ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS I; Mizpotal *pMem Con$tructton Permit Permission is hereby granted to Construct( )Repair( )Upgrade(,,)-Abandon( ) System located at �ww 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 permit. Date: Approved by - 1/6/99 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 PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works C q(0 construction permit signed by me dated 10� , concerning the property located at meets all of the !off following criteria: "• This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. P/• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. K There are no wetlands within 100 feet of the proposed septic system J• There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed tpo" There are no variances requested or needed. The 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 asing the Frimptor method when applicable] 01/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) ISO i B) G.W.Elevation .0 +the MAX.High G.W.Adjustment. = C� DIFFERENCE BETWEEN A and B 'r SIGNED : DATE: i [Please Sketch prop d plan of system n back]. II NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. j q:health folder:cert i �l y. 1 Jvo