HomeMy WebLinkAbout0021 STONE HORSE ROAD - Health 21 STONE HORSE RD. OSTERVH.LE
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TOWN OF BARNSTABLE
LOCATION Jf 4Tor�1h /i,�"S/i l � SEWAGE # F,7^ Vf
VILLAGE _ � � OC 11 �� ASSESSOR'S MAP &LOT/112 7'/.,,"
INSTALLER'S NAME&PHONE NO 4/77^ D3'19
SEPTIC TANK CAPACITY
LEACHING FACU ft`Y: (type) Pr/ cv, /l(size)
NO.OF BEDROOMS
BUILDER OR OWNER Sr6YZ- 14 Tr
PERMTTDATE: 26 ^ Sgl 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 A feet of leaching facility) Feet
Edge of Wetland andleaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �;—Ve4
,. Frp�tT
_ O A
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Fee
No.
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
s
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
3pprication for 0igpo9;ar *p!6tem Congtruction Permit
Application for a Permit to Construct(vj Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.4 I 5-ime— HohsF 4W. Owner's Name,Address and Tel.No.
o,rr�H�t;rt Assessor's MaMap/ParcelSrew 61411-rahs
(Y2 !/S' r At 49
Installer's Name,Address,and Tel.No.Z{7'! D'.f 9 Designer's Name,Address and Tel.No.
Jo s,JO* Qc. d o.~o 0 04.
i /ti> �ls
Type of Building:
Dwelling No.of Bedrooms `Z' 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 $ash
Natured Repairs or Alterations(Answer when applicable) 42" zs !af
a oc�t'h' antetvr3!
off N
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 by this BMY
f Health.
Signed u,[it.�i?r Date
Application Approved by Date ^
Application Disapproved for the Mlowiny reasons
Permit No. D Date Issued
----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(4-)-Repaired ( )Upgraded( )
Abandoned( )by /os f-0/1_o.e- S AM,*'o S-
at 2! S tA.1 e- ymr 4-L 61 esrr_ryzY/: has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.�!-30 dated
Installer rro Designer. v 0
The issuance of this permit of be const ed as a guarantee that the syste 1 nction as desigrld.
Date I Inspector
No. 2�—a.Z� s Fee Vs
THE COMMONWEALTH OF MASSACHUSETTS-� Entered,in computer:
"+4
`PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE.,MASSACHUSETTS
Zipprfcatfon for bfgpogal *pgmem Cow5tructfon 'Permit m
Application for a Permit to Construct(ems-)Repair( )Upgrade( )Abandon( ) ❑Complete.System . ❑Individual Components
Location Address or Lot No. / 51,04 G H0e5's Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel
/5'2
Installer's Name,Address,and Tel.No.4 71 —0141 9 Designer's Name,Address and Tel.No. �# '
° k: 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 5A4cr/
Nature of Repairs or Alterations(Answer when applicable) o X's
Ay,:,/. cad-4 oa G S Mao6AV, u i_/
w,1A y ' SToH-c k4s1a4l.o
,y
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 by this Board of Health.
Signed Date AS'-?G-9 '
Application Approved by Date
Application Disapproved for the Wilowiny reasons
a
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1
Permit No. O Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(tertfffcate of QCompliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(4_),.Repaired( )Upgraded( )
Abandoned( )by "J0
at 2/ �?a 4 c_ Hoe.4 L �u>< /.I Srl;: ^j/i%//; has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. _50 c dated
Installer ,/osr_,dX { Ave.-oS Designer n
The issuance of this Permit sha not be onstrued g y as a guarantee that the s ste illAf nctlionn as desi ne
Date / Inspector gl� VU
f J
\ to
j�
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No. Fee
7 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Of 5pogal *pgtem Con mructfou Permit
Permission is hereby granted to Construct(Repair( )Upgrade( )Abandon( )
System located at 2/ j ra i-e Hors. ' /2u�
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 permit.
Date: _�-(� - +% Approved by N 7�
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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)
.L Js-,�AtiV-e 9,41n,4 S hereby certify that the application for disposal works
construction permit signed by me dated Sr'^ G9 concerning the
property located at -V {forSit /2� asr�r✓r/�� 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.
�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
• ere 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
mammum 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) Jr
B) G.W. Elevation +the MAX. High G.W. Adjustment .J W =
DIFFERENCE BETWEEN A and B
SIGNED : '& 'va-lam— DATE:
[Sketch proposed plan of system on back].
q:health folder.cat
TOWN OF BARNSTABLE
LOCATION :Z/ STo h �/��S/= %� SEWAGE #
VILLAGE �����V J ASSESSOR'S MAP &LOT /' 2 LL
INSTALLER'S NAME&PHONE NO. 4r7
SEPTIC TANK CAPACITY LW
LEACHING FACILITY: (type) 3,SA2 6µ i 4i-v (size) A' /
NO.OF BEDROOMS
BUILDER OR OWNER re a�S
PERMITDATE: 5' ^ 91, COMPLIANCE DATE: 27-5; ?
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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
540
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