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HomeMy WebLinkAbout0151 HOLLINGSWORTH ROAD - Health EHOLLINGSWORTH R STE o 0 0 TOWN OF BARNSTABLE LOCATIONO Zd1-11 612 SEWAGE # �9 VILLAGE O5Ze4 Jl,4& ASSESSOR'S MAP& LOT/t INSTALLER'S NAME&PHONE N0. �ic,�ey SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _7 X ® 7tl eod(size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: wliqCOMPLIANCE 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 �P /1 � - �t/t7M� �10i1J�' �, Z �`S-i .D d . No. d 9 Fee �� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[pprication for Migpool *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( �u5pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address 1or Lot No. r Owner's Name,Address and Tel.No. ,S, loll"+V W() -L ©STCy.,te ^ N: Assessor's Map/Parcel �1 t-Ne 11 1 0 ^ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ? % Lk m_t 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 Nature of Repairs or Alterations(Answer when applicable) \1^9�-,Ik 4 4-0 S;C4 c1�4� 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 this Board of,Health. Signed Date Application Approved by Date 2— 19. ZP Application Disapproved for th following reasons Permit No. — 571 Date Issued No.� — _ Fee — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _I_-� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for Migpoga1 *patent Construction Permit r Application for a Permit to Construct( )Repair( pgrade( )Abandon( ) El Complete System ❑Individual Components " Location Ad ss or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel C, lyo - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �e N���Qy �drSr Type of Building: Dwelling No.of Bedrooms Lot Size sq. f.. Garbage Grinder Other Type of Building TT 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 1 Nature of Repairs or Alterations(Answer when applicable) VASv-,kk 4 �ovS,t d.:Ai Ox r 6h�. \�0.C�►\tiG Q�M•¢rC�+ °� 5 Cs� ,C.. Date last inspected: Agreement: 4 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. Signed Date Application Approved by Date Application Disapproved for th follo ng reasons Permit No. Date4ssued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( ✓j Upgraded( ) Abandoned( )by 0.c-k Q Y 0.Zr at / 1 in d has been constructed in accordance with the provisions of Titlet and the for Disposal System Construction Permit No. - dated . Installer I Designer The issuance o • i permit /hall not be construed as a guarantee that th s w -un tion as� siglYe alp, Date cil Inspector r ��� I �n L, --------------------------------------- No. / 9 — Q Fee �CL THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigoar *p5tem Conotruction Vermit Permission is hereby granted to Construct( )Repair(✓)Up rade( )Abandon( ) System located at 17( m0firfles or rc. 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 perm_t. Date: r p'—/q�l Approved by r 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) I, hereby certify that the application for disposal works construction permit signed by me dated Q--2o.—'I concerning the property located at 15-t xro'4' meets all of the following criteria: ti • The failed system is connected to a residential dwelling only. There are no commercial or business usesassociated with the dwelling. • The Soil ' assified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • '.re are no wetlands within 100 feet of the proposed-septic system Ve 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 anv 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 +the MAX. High G.W. Adjustment. _ DIFFERENCE BETWEEN A and B SIGNED : DATE: (Sketch proposed plan of system on back]. q:health folder:cert �r i e^ O UCH _-- _. �4 TOWN OF BARNSTABLE LOCATION01 SEWAGE # VILLAGE OS Tt._- �e ll ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: ( ) y X .75- h (size) NO. OF BEDROOMS BUILDER OR OWNER r (� PERMITDATE: 1 COMPLIANCE DATE: 'I i 1 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 91 ,✓ ti G � Q