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HomeMy WebLinkAbout0320 MAPLE STREET - Health 7320012 MAPLE ST., West Barnstable A=131. � e - e 1 { i I e I TOWN OF BARNSTABLE J �l" LOCATION / SEWAGE # VILLAGE ��/��r� !! ��� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /Joo G LEACHING FACILITY: (type) 1�v��fi,� s �� (size) NO.OF BEDROOMS 3 BUILDER OP<�0 4111ali�2,19 PERMUDATE: tZZ! 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 200 feet of leaching facility) /5—O f' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) l�/� Feet Furnished by o 3q rY . O i _7101- 11 porgy / `� ►�� r Fee No. / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for r3i_4pogal *p5tem Construction Permit Application for a Permit to Construct( )Repair(�/)Upgrade( )Abandon( ) W Complete System ❑Individual Components Location Address or Lot No. � � �Q�� 6� Owner's Nam ,Address and Tel./ � Assessor's Map/Parcel (1,9 rl 474 ® r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder Other Type of Building PGe No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 25® gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �✓®D Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)r/ fle Z?� 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 o of ealth. - Signed Date Application Approved by C_ Date Application Disapproved for the following reasons Permit No. Date Issued Z t i i q3 ll� to E i pars' Z TOWN OF BARNSTABLE LOCATION . ,?,0 /td $ SEWAGE # -$-,j VILLAGE > % ASSESSOR'S MAP & LOT 31-101 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /s`oo G;L LEACHING FACELITY: (type) sw 4 1 (Q) /ems (size) NO.OF BEDROOMS 3 BUILDER OF<�o PERMTTDATE:_ COMPLIANCE DATE: Separation Distance Between the: i 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) - /S-O t Edge of Wetland and Leaching FacilityFeet within 300 feet of leaching facility any Wetlands exist Furnished by A Feet o.N Fee S () THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes r� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for aigaar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) LJ(omplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address an Tel.No. R Assessor's Map/Parcel 7© Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( d Other Type of Building l—.9 Ce 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 J�o Type of S.A.S. �}361)2-0) SOX Description of Soil Nature of Repairs or Alterations(Answer when applicable) fle v/— 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 BoarA of Health. / Signed Date Application Approved by C_17 Date Application Disapproved for the following reasons Permit No. Date Issued 4r --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance / THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(v)Upgraded( ) Abandoned( )by at AID Gv D/it5+1`a has been constructe in a cQor ce with the provisions of Tide 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not a construed as a guarantee that the system will function as designed. Date Inspector ---------------------------)----------1-- No. r 3/ ©1Z Fee -� " I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS xigpogar *p5tem Congtruction permit Permission is hereby granted to Construct( )Repair(Y)Upgrade( ,j)Abandon( ) System located atZz� 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.py g p p � Provided:Construction/mu t be completed within three years of the date of t ' t. Date: /?% /�� Approved b t o/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) 44 hereby certify that the application for disposal works construction permit signed by me dated �!/�C�� , concerning the P g property located at �� ��1� 1w/ 'AP°`"P1046l� meets all of the following criteria: i,/ There are no wetlands located within 100 feet of the proposed leaching facility /There are no private wells within 1-40 feet of the proposed septic system a✓ There is no increase in flow and/or change in use proposed V There are no variances requested or needed. /Ir the proposed leaching facility will be located within :40 feet of znv wetlands. the bottom of the proposed leaching facility will w be located less than fourteen (la) feet above the maximum adiusted groundwater table elevation. Please complete the following: �f _ A)Top of Ground Elevation(according to the Engineering Division G.I.S. ma. ;► y`v" B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: 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.art 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) 1 hereby certify that the application for disposal works construction permit signed by me dated ,concerning the property located at meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells withinl!-40 feet of:he proposed septic system • There is no increase in flow and/or chanee in use proposed • There are no variances requested or needed. • ff the proposed leaching facility will be located within=50 feet of any wetlands,the bottom of me proposed leaching facility will pQ[be iocared'ess than rourreen i_1sl;eel 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.) B)Observed Groundwater Table Elevation(according to Health Division weil:nap) SIGNED: DATE: 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;balth folder.an o � i C✓ 4X,4 IL I I I L C