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HomeMy WebLinkAbout0170 HOLLINGSWORTH ROAD - Health 170 HOLLINGSWORTH R® OSTERVILLE A = o _ 0 0 0 v TOWN OF BARNSTABLE V& LOCATION / J 2Z4 SEWAGE # VILLAGE © ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /12 20 Cd,,2 f C�F'�f� 7 22 SEPTIC TANK CAPACITY LEACHINGFACEL=: (. pe) (size) `/ /1Xa- NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: r 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 7-9 f/ I d If TOWN OF BARNSTABLE LOCATION / s a SEWAGE # VILLAG ASSESSOR'S MAP 3; LOTIOLO INSTALLER'S NAME&PHONE NO.` ' _C-& Z r-, SEPTIC TANK CAPACITY / Sv -r,.fit LEACHING FACILITY: (. pe) /.st/ ��..�Jd2 C (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE:. Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet i 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 I Y 12S 41 z 3 Z 113 3 No.—, / �j Fee;? / 1✓' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Digozal 6pztem Cow6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) *Complete System ❑Individual Components Location Address or Lot No. 1-70 ` 1 t.LC) Owner's Name,Address and Tel.No. Assessor's Map/Parcel 0�--Qt* � *-erf a( SU-1e -- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. { S S1-� Y 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 14 L/0 gallons per day. Calculated daily flow qe,�, gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1__s� S j?'LIC-_T04-� Type of S.A.S. ! cC LTsgvxS /d Description of Soil y�nn— LS Ac Nature of Repairs or Alterations(Answer when applicable) / ^477 S e�7�G Tie1�� �✓���� 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 be ar Signed Date Application Approved b Date Application Disapproved for the following reasons Permit No. A Date Issued G No. d �i✓ � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS res , 01ppYicatiotflor 10,i.5poml-6pgtem Construction Permit 3 i t. ; Application for a Permit to Construct( ')Repair( �)Upgrade( )Abandon( ) Complete System ❑Individual Components ` Location Address or Lot No. 1`70 p` ( S av C Owner's Name,Address and Tel.No. Assessor'sMap/Pazcel � ��; �(�{_ y �J Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.,. S_r� ffy ' Type of Building: a r` Dwelling No.of Bedrooms V Lot Size sq.ft. Garbage Grinder 1" r Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow q y U gallons per day. Calculated daily flow � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /__��UnnS P"r L "rtIO!`K Type of S.A.S. ' ik- :L&NetL 7/4 III aPs Description of Soil Nature of Repairs or Alterations(Answer when applicable) / O7� S�'/�"'f G T�4 rv�C. t✓`1S oY, 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 bee oar . Signed Date Application Approved b Date Application Disapproved for the following reasons / P Permit No. � Date Issued ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS f BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded()4.) :t Abandoned( )by % -C 5 at D © lw ccJO/f' - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated .14.- ..� Installer Designer 14 The issuance of this t shall n t e construed as a guarantee that the sy t- �Jifi1 function/as d i ned� � .4w Date ! Inspector {/� 1� / _ � ,l f ��c ------------- ----------------- ------ No. � ,.,' — —— Fee .. r -- --- - THE.COMMONW-EAIKT14 OF-MASSACHUSETTS - - - PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS 1=i9;po5a1 *p5tem Conotruction Permit Permission is hereby granted to Construct( Re ' ( )Upgrade( �an ( ) System located at / -70 Ilt -trrS r ri c7- l l� and as described in the above Application for Disposal System Construction Permit. The applizant 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 thispejrmt. Date: 1161 '' -'� � Approved L 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 /6`�L�-�j concerning the property located at 0 (,ua. I C meets all of the following criteria: (/• The 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. C>,/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 �ere 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 Ithod when applicable] o 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) /t ) B) G.W. Elevation 'y +the MAX. High G.W. Adjustment `� DIFFERENCE BETWEEN A and B p� SIGNED : DATE: (Sketch proposed an of system on ack]. q:health folder:cert i,� Q , t