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HomeMy WebLinkAbout2743 FALMOUTH ROAD/RTE 28 - Health !' 2743 FALMOUTH RD. \ OSTERVILLE A = 121 012 001 I TOWN OF BARNSTABLE � LOCATION 27y Z61 �1� y'A7�Y/tSEWAGE # © _ 3 `PILLAGE ASSESSOR'S MAP & LOT ?-I"012 '0� INSTALLER'S NAME&PHONE NO. W l um,T,�V �7� SEPTIC TANK CAPACITY �C7� ww L��L LEACHING FACILITY: A 1A1(0 l``.l�?t 1l° 1 ZIrI�s�.� 905 A ?J `x z NO.OF BEDROOMS BUILDER OR 0MR �OWl VI MA PERMITDATE: Z COMPLIANCE DATE: bf Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 14 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 c _ - lot ,3 '32 . ^� y 176` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppricatiou for Mtgoar *pgtem Con!6tructiou Permit - Application for a Permit to Construct( . ) pair A G)Upgrade( )Abandon( ) Complete System El-Individual Components Location Address or Lot No. D Y �� Owner's Name, ddress and Tel.No. 5t76— -1-71—3 q 5/ 1�� Assessor's Map/Parcel In taller's Name,Address,an el. o. 50�—1� l— Designer's Name,Address and Tel.No. arn. ,-r'durle� LA lRt-Gm,�)t� �Gcr�niG� Type of Building: w lin No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow I l o gallons per day. Calculated daily flow 7 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �J �Q G Type of S.A.S. `J Description of Soils/4,1��'YZ ,��%� Nature of Repairs or Alterations(Answer when applicable) ,)A4 Date last inspected: lCO. 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 the n ' nm tal Code and not to place the system in operation until a Certifi- cate of Compliance has been i u t is o alth. C/ ) Signed Date_— Application Approved by �� Dates Application Disapproved for the following reasons Permit No. Date Issued �' �ls No. Fee /r .w /`j e} THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS V/ ZIpprication for Migaal *p.5tem Construction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System El Individual Components Location Address or Lot No. Owner's Name,A dress and Tel.No. Assessor's Map/Parcel 66 rvI Installer's Name,Addres , d r�pv-1 1 l'q-�cl Designers ame,Adtlress and Tel.No. Wrn.q,-reor V6 d b f�- skr 0_on�t- o&-66 n p of Building: r hrg No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) e—r" 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 Da e Title Size of Septic Tank — _Type of S.A.S. Description of Soil �T iI V1 I I ` z s r r� Nature of Repairs or Alterations(Answer when applicable) Le,J6 i Date last inspected: _ Agreement: ti 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 o f th nvir nmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t is Bo rd:of alth., Signed f1t , Date j --m�Application Approved ,, .. _. ; " Date Application Disapproved:for t e following reasons Permit o. .ri 9 -,T� Date Issued p ---- —ay———————— ----------------------- 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 itle andthe for isposal I C 1, ons1 1 tion Pere dated fZ a&f Installer i 4e Designer The issuance oThts permits all not be construed as a guarantee that the cyst m will function-as designed Date Inspector --------------------------------------- �? No. Fee�7 ZZ F THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwizpozar *pztem Con5truction Permit Permission is hereby granted to Construct( Repair( )Upgrade( )Abandon( ) System located at l 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 pe t. 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 PERNNIIT (WITHOUT DESIGNED PLANS) I, u)(W on � ��, hereby certify that the application for disposal works construction permit signed by me dated 2_ concerning the property located at ?-7 meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. . �✓' The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. Li There are no wetlands within 100 feet of the proposed septic system 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 •' 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 using the Frimptor method 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 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) B) G.W. Elevation 7-6 +the MAX. High G.W. Adjustment. _ A2 DIFFERENCE BETWEEN A and B SIGNED : DATE: �_ b [Please Sketch proposed An of system-on back]. '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. q:health folder:cert t `t Q, r c-- Ai\ (� TOWN OF BA.RNSTABLE - LOCATION ���� V' SEWAGE # �?3 VILLAGE ASSESSOR'S MAP & LOT±Z f-012 -00 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S00 LEACHING FACILITY: ( 1(®t �� �i 1� "�7i C rj x `X NO. OF BEDROOMS Z BUILDER OR OWNER AotAk1, PERMITDATE: Z (7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility __A.Feet Private Water Supply Well and Leaching Facilit y (If any,wells exist 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) A Furnished;by Feet - 3q•5' 10 ` f l C q AN. 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