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HomeMy WebLinkAbout0218 CRYSTAL LAKE ROAD - Health 218 CRYSTAL LAKE 174 �OSTERVILLE A=139.048 1 d 1,l 6 0 TOWN OF BARNSTABLE LOCATION U�676P'l Z, e SEWAGE # �-7S� VILLAGE 695 l/! e ASSESSOR'S NW & LOT / —eVq INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S�t1 v LEACHING FACILITY: (type) . 2 (size) �C NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 G TOWN OF BAni,,S TABLE E C� LOCATION u �T}/f� .L�r � P SEWAGE# -- VI LAGS v �� ASSESSOR'S MAP &LOT L —fig INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /C d LEACHING FACILITY: (type) 2 T/,�/'��ajd (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: `J'—W'f$ 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 Feet within 300 feet of leaching facility) Furnished by NoVy No. FeeL1—.��� THE COMMONWEALTH O MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprtcation for �Dtgpo!5ar *p5tem Cow6truction Permit Application for a Permit to Construct( )Repair(V )Upgrade( )Abandon( ) 21Complete System ❑Individual Components Location Address or Lot No. '? G ✓5 f�•/ �• r Owner's Name,Address anndd Tel.No. f Assessor's Ma /P. elr�//��f / gWL f / � 0. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1®j1k% 7 ••'Type of Building: •• • • Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( D • Other Type of Building No. of Persons Showers( ) Cafeteria( ) • Other Fixtures Design Flow gallons per day. Calculated daily flow �7�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 3 SdD 9���G'rl o Description of Soil eQG C S /10 3G' Z 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 b his Bo d oUiealth. Signed 12 Date dl/% Application Approved b Date � � Application Disapproved for the following reasons Permit No. Date Issued//--f �-� No. `:;� �7 Fee THE.COMMONWEALTH O MASSACHUSETTS Entered in computer: tYesl PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 0[pprication for 0i5po0ar *p5tem Construction Permit Application for a Permit to Construct( )Repair(V1)Upgrade( )Abandon( ) TIC410mplete System ❑Individual Components Location Address or Lot No. x/g G r! -:�fw/ Zak I- Owner's Name,Address and .,_ Tel.No. Assessor's Ma /P el r(//�,�� /'/ � <P7/V Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/ 9�9 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( D Other Type of Building �O.5 �ehle No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //0 gallons per day. Calculated daily flow 3 3D 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) �� /� Z7 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 b his Board of Health. Signed Date ////Z Application Approved b aelzidfDate //�► .e�� Application Disapproved for the following reasons` o� ram' r i i 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(V )Upgraded( ) Abandoned( )by at 5 C/i e >''�/� as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. . _ ., dated�� Installer ! Designer e A n i;, The issuance of this perrLrs,all/not be construed as a guarantee that the es�rw 11 functi in asdesi�gned. Date No. �� —��----------------_----- p��� v L, Fee---- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigogaf *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(y,<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 thi ermit. Date: / �^""' !� Approved �r r� 10/9/97 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 ENGINEERED PLANS) I, Ag Je/'7- T, �3®hl�� ^, hereby certify that the application for disposal works construction permit signed by me dated I"/ff , concerning the property located at Z&'!�'I^067 7 L4,le i^c�' ©Sfe/'yi/meets all of the following criteria:. k/ There are no wetlands located within 100 feet of the proposed leaching facility 4/ There are no private wells within 150 feet of the proposed septic system 4/ There is no increase in flow and/or change in use proposed '4 There are no variances requested or needed. d If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=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) 30, 7 B)Observed Groundwater Table Elevation (according to Health Division well map) /® SIGNED : DATE: 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.cut L �D 01) I PAL i I I I 1 ti I 1 i j