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Home My WebLink About0118 HICKORY HILL CIRCLE - Health 118 IIICKORY IIILL CI YXOSTERti ILLI A=121-054 LOT 57 v c I e �'J Fee No. .J7 THE COMMONWEALTH OF MASS HUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARN TABLES MASSACHUSETTS Zipprication for Mi5pogal *p5tem Construction 3dermit Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System O Individual Components Location A iy s or Lot No. 1l sj � j C k Ur {'+�C C i ner's Name,Address and Tel.No. co e Ile /, _/ Assessor's Map/Parcel a o �s Installer's Name,Address,and Tel.Nc. Designer's Name,Address and Tel.No. sco tj 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 S, e Nature of Repairs or Alterations(Answer when applicable) t �5'I t�� Pr c,! (ri 0 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 Enviro t 0n(IP apd not to place the system in operation until a Certifi- cate of Compliance has been is d by this B d of alt Signed Date /P� Application Approved by Date " Application Disapproved for the following reasons Permit No. Date Issued G p L"L A h-, Q Qx ,Z(� P�A-o TOWN OF BARNSTABLE LOCATION .Ll 1 C:GC" Ht�� C �rf SEWAGE # 7 VILLAG ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ,�S C Es—�-<- 7 7 J 1S 2 SEPTIC TANK CAPACITY MU � Q�C LEACHING FACILITY: (type) <3 r%'X (size) G�/ V F-' IS NO.OF BEDROOMS \ BUILDER OR OWNER PERMTTDATE94L-'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 exist on site or within 200 feet of leaching facility) Ay cl-, C Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by No. Fee THE COMMONWEALTH OF MASS HUSETT'S Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARN TABLES MASSACHUSETTS Yes Zippficatton for ]Di-qpogar *p!gtem (Eoi%truction Permit Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System ❑Individual Components Lopat' Add s or Lot No. �j J�j� U H( C}r Owner's Name,Address�l.No. Assessor's Map/Parcel \ .r Installer's Name,Address,and Tel.No. •7 Designer's Name,Address and Tel.No. 75- Svgc► o1c( I�G.�� C?d (AM' ---,Ty Pe 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.i 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' C<_ ex(5�1`� 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 Enviro and not to place the system in operation until a Certifi- c`ate of Compliance has been iss d by this B d of alt Signed Date Application Approved by Date '° d Application Disapproved for the following reasons Permit No. °°' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO C��T_IFY, that the On Abandoned by Sewage Disposal System Constructed( )Repaired( Upgraded( ) ( ) ` at C<r 4 04-Z4,44 has_been constructed in accordance with the prov' ions of Title 5 an the for Disposal System Construction Permit No. "' dated Installer Designer The issuance of this permit shall no be construed as a guarantee that the system will function as designed. Date 1 - { X Inspector "' --------------------------------------- No. A + fi Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS I=igpo.5ar *pgtent on.5truction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon(A System located at / 'E f Cyr I ` c- t C I 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 p Date: '" Approved by - TOWN IOF BARNSTABLE LOCATION ,�� (G kcry /1,�r C(�� SEW GE # VILLAGE/-)-N, V 1 ASSESSOR'S MAP & LOT I l!- bill INSTALLER'S NAME&PHONE NO. 'ti SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /-,)C.X 1 (size) 'NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Aa Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /�.iU'`'t Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A� r � d S 1 35 _ A 4v 0 ax Nou 2 � Y 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) !r 1, !]SZ G 'cam c--�,\`� , hereby certify that the application for disposal works construction permit signed by"me dated concerning the located at meets all of the property I } � f � following criteria: /There are no4etlands located within 100 feet of the proposed leaching facility - There are no private wells within ISO.feet of the proposed septic system �. 1 There is no increase in flow and/or change in use proposed There are no variances requested or needed. f e,ir- 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.a �' Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: l LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER r l [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. r- q:health folder:cert --��,� o�'�� r11��,1 U ��d �`� s O Q ��