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HomeMy WebLinkAbout0499 OLD MILL ROAD - Health 499 61d Mill Road 166-004 - Osterville A e 4 Y P a S� G f Gt M i��OWN OF BARNSTABLE C,`C a I LOCATION SEWAGE # 61®O4 —6*99 VILLAGE!J42 ®Lb MILLP-►® d SIC-RUILLI ASSESSOR'S MAP & LOTl�6- INSTALLER'S NAME&PHONE NO: F 1111 E R B 0 ZC-AT.S z ay a e E SEPTIC TANK CAPACITY 1 00 Q-AIX00455, CAMBeLft, LEACHING FACILITY: (type) /500g1-TAb 3-!6*0p9(size) ,13 X NO.OF BEDROOMS 4 STONE ALL Att®u;j® BUILDER OR WNE PERMTTDATE: ff COMPLIANCE DATE: 3 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 /,A0tiT �aaet� A—J /6� A A—3 �V spy 3` ' p�oo ; A-CAR g : � ` to rot 1 w, ® P; a No. �OU�(_ ,.µ FEE�. � Board of Health, S fie.. , MA. APPLICATION F®P, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - &'omplete System ❑Individual Components Location 1' V G-b MILL- C)A Owner's Name'mp PeaAy Map/Parcel# 66 7 Address Lot# Telephone# Installer's Name Designer's Name" ,4 Nkee su"Ve C`_v,45ucrw-t Address Address ��uS` R ~k-St-US /17/6'h Telephone# Telephone# d$— 0 S5 1 .,f Type of Building L Lot Size IAA sq.ft. Dwelling-No.of Bedrooms 7 Garbage grinder WO Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow ��® Design flow provided gpd Plan: Date 8-17—©y Number of sheets Revision Date Title S 1 rtr S-elO±t C. Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluat (tX>C v %, Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS y: The undersigned a , to install the abov .de'ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to no place the syst operation until a Certificate of pliance has been issued by the Board of Health. Signed Date Inspections i (' .� d M,,I/TOWN OF BARNSTABLE LOCATION _ SEWAGE # Q®q"S9� i VILLAGE!JQq QLb MILL" QS`T01i91'LLti ASSESSOR'S MAP & LOT1 i- INSTALLER'S NAME&PHONE.NO. Ff 5hE9, Lai0'aCG lT.S£Rif ICF- SEPTIC TANK CAPACITY Z--5"00 &_4i.1L0e45 LEACHING FACILITY: (type) t'��et -JK -S-560% (size) k; X 33 4 NO.OF BEDROOMS 4/STOAF Ai.L ARauab BUILDER OR OW 4E PERMTTDATE: Il COMPLIANCE DATE: 3hy 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 I!�AC - i A-3201 pia, a Ov LU 4 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) i �- I I M AC(� L DATA N- % v, ."..:r' / `y+^ G yq} J ysr► z s it..r4w ._ x FEE Ji ' uBoard of Health, , �.S�u-`�,r.>� ' MA "'" F " APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT p Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - _ZWomplete System ❑Individual Components a� Location �- 7 ©G� I JLI- UyQ Owner's Name-T?,O a le Map/Parcel# 71 / Address , Lot# Telephone# Installer's Name e Designer's Name Y,4 duleee SUIVI?l d CA4 50(__r#q K Address ! Addressz/0',g c��IciuS� R Telephone# Telephone# Type of Building Lot Size sq.-ft. Dwelling-No.of Bedrooms ' Garbage grinder A0 Other Type of Building l C d No.of persons Showers ( ),Cafeteria ( ) ` Other Fixtures Design Flow min.re uir d �� l d Calculated design flow �`"pd*g ( q e, ) ;� ;gp g c/�� Design'flow provided�_�< gpd t� Plan: Date SP 7`'�7 Number of sheets Revision Date Title f,, �? Description of S.oll(s) a 1" '�,5tSbil Evaluator Form�No Name of Soil Evakiaf' Date of Evaluation c, 3 A DESCRIPTION OF REPAIRS OR'ALTERATIONS ! f ` + r .00041 I fie Theundersigned agxe s to install the abov�.described Individual Sewage Di ,osal System in accordance with the provisions of TITLE 5,'and 'further agrees tq>iio place theem m operation until a Certificate of pliance has been issued by the Board of Health. n *r - Signed - Date , - �Y�','.•�f s �. - ,.,' R y t ,..SM s t., ;_ �i _ -. Inspections `. r a FEECus l (J Board of,Health, 1�Q.lh 5�. `�, a �)MA. -CERTIFICATE OF C045ANCE Description of Work: ❑Individual Component(s) O-eomplete System , The undersig ed�hereby cer . that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) at yq �G� /COI L�.. R °4 1:> has been installed in accordance with the previsions of 310 CMR 15.00 (Title 5) and the approved design plans/aS-built plans relating to applicat on No. ('jJU ^��/ dated f f! U Approved De%n Flow!Sy 4 (gupd) Installer Designer:Vep6re ye eot'Sucr4ei inspector:- Date: D The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. UU�" FEE COMMONWEALT14 OF MASSACHUSETTS w Board of Health, If MA. ➢ISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(t.)—Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system � at as.described in the application for. Disposal System Construction Permit No. doo ^'S dated - / Provided: Construction shall be completed within three years of the date of s per i . All local` nditions must be met. Form 1255 Rev.5/96 A:M.Sulkin Co.Boston,MA Date Board�—�1 U�Board of Health i k,�C yO �r /!S) �()!' j/i[: P(Ll�� �rP 1r rS f S✓?�y w _ - — 'j r • Town of B;a.rnstable . , . HE Regulatory Services Thomas F. Geiler,Director • eaRivarhste, • • 9KAM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 2 ( Designer: AC%_k"re S Q I v:n Installer: z ah�_ Address: 41" i, T-A A-. I-V'N L Address: y7d / ems O'IN C On ' was issued a permit to install,a (date) (' stiller) , septic system at (> /�I f/,> 0) . based on a design drawn by (address) 6. iNi�✓� h ,$ dated b C' /of (designer) y I certify that-the septic'system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 1 certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical.relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. 4� 1'3 Ink IfitBRUCEG. '9a er s Signature) MURPHY No..749 T 1 - (Designer's Si e) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. 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