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HomeMy WebLinkAbout0404 LAKESIDE DRIVE - Health 404 LAKESIDE DRIVE, MARSTONS MILLS A=102-037 � --- `- - J \ C/ - TOWN OF BARNSTABLE LOCATION y 24 LCAC.S o�C_ br SEWAGE # VILLAGE Kam Y®y.A ASSESSOR'S MAP&LOT - INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l 111_�00 ,LEACHING FACILITY: (type) _(size) 6*0)CV X NO.OF BEDROOMS �w BUILDER O'�Oi�R PERMTTDATE: '1-3 I COMPLIANCE DATE: Separation Distance Between the: j 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 y wetlands exist within 300 feet of leaching fa Feet Furnished by 0O L ��-.s-yam-- No. Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[pprtcatfon for Mi!6pooar *p!tem Construction 3permit Application for a Permit to Construct(` )Repair(Xupgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. L GABS,p L ��`v b Asses or's ivy/Parc^I O.. ' AAA �� �� e�l��n� Installer's Name,Address,and Tel.No. Designer's N e,Address and Tel.No. -T- LA 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 0 Nature of Repairs or Alterations(Answer when applicable) JY � I l 500 601 L Xul LJ XZ' 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 Cke Date 8')2 Application Approved by Date Z Application Disapproved for the following reasons ���— Date Issued Z T , No. S/ m Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Application for Mtgoar *p5tem Con.5tructton Permit r' Application for a Permit to Construct( ' )Repair( V�Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Asses or's Iv�p/Parcel O3 ,�w ��� 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. / J Type of Building: ." Dwelling No.of Bedrooms 21 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 © CbAK-s-_ i. Nature of Repairs or Alterations(Answer when a plicable) • v rt e`FIST\•, r 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 r ��•► Date 'R ZY q Application Approved by C Date z l� Application Disapproved for the following reasons Permit No. j —Sir Date Issued Z THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ).Repaired( )Upgraded( ) Abandoned( )by (3 v" - at 4 by WKP)­dL. 't� NM. µ-1 has been constructe in ac r with the provisions of Title 5 and the for Disposal System Construction Permit No. dated g L Installer (Ai ,k-c-Y t4 u h -- Designer The issuance of this p t shall not onstrued as a guarantee that the system will function as designed. Date Inspector �—��� ------------------------- No. / Fee SVI THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Moon[ *pgmem Con5tructton Permit Permission is hereby granted to Construct( )Repair(upgrade( )Abandon( ) System located at 40\.( LA'VCES\,DL 1�,`_-- 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 b completed within three years of the date of this ei it. `n Date: �/ Gy Approvedby J/ { } 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) hereby certify that the application for disposal works construction permit signed by me dated g—ZX —`l , concerning the property located at �ft 14CON-� byoe, tk*`� meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • 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. • 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. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) If W B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: o,_ DATE: 2�( LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert z fl U r 4V C _ 60 4 III o 00 60 � TOWN OF BARNSTABLE LOCATION �`��- �r SEWAGE # �\ 9�- VILLAGE �� �`^ � ASSESSOR'S MAP & LOTLO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l .SOD LEACHING FACILITY: (type) T "`�� (size) NO.OF BEDROOMS— BUILDER 041,11, OWNER PERMITDATE: COMPLIANCE DATE:_a 4ur�Ir Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility y wetlands exi`i Feet within 300 feet of leaching fa ' - Furnished by a=' , FTT f --=- ; lzrf .� I — � � I l �►'v 3 I r—ot_� i I i I I Z i , b i � l AL- ------------------ ' it { � a �l lTTT KEM-9JC E)c�ST w i IN ow 010 I II _ _ . � M (I 2' S i=F�e•J) %�C R�19T'E ST�R'F,�'t= '•-�r''.Jt it ..-T�t,+�:. + New - f SCALE:. �� _ _ APPROVED BY: [�REVISED AWN BY 4 0 71..,.. /,-. DATE: Ll l ---_— — _- DRAWING NUMBER LEr-r ..c .!r' .^i1 1 i - I -------------------- KE= f O J 0 i 2Df i i i _ I � I a i i