HomeMy WebLinkAbout0031 EEL RIVER ROAD - Health (2) - ���e,ry��1,1�, - 11 to- 10(o
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TOWN OF BARNSTABLE
LOCATION 3► EEL SEWAGE# ,209.1
VILLAGE ASSESSOR'S MAP&PARCEL 116—/0(„
INSTALLER'S NAME&PHONE NO. �D. ►�fcyvun► �IuC
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) SOO��CJft,4P(% (size) 3 3 12-70
NO.OF BEDROOMS
OWNER CGdOto-I (C/
PERMIT DATE: P / COMPLIANCE DATE: `llahu
Separation Distance Between the: NO 644) 'FNf oulwfP�
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"a A 9
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Town of Barnstable
Regulatory Services
Richard V.ScA Interim Director
Public Health Division
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rAR< Thomas McKean,Director
200 Main Street,Hyannis,MA 02601.
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: 4202022 Sewage Permit# 2021-089 Assessor's Map\Parcel _ 1161106
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Designer: S &C mmitin In
Address: 711 Main Street l PO Box 659 Address: 0 1 �X 1 Ll.S
Osb wAVe,lA 026% J�P(V l �2 cti.O12,61 3`Z__-
On 323/2021 M was issued a permit to install a
(date) (installer')
31 Eel River Road,Owe
septic system at based on a design drawn by
(address)
Sullivan Engineering&Consulting,Inr- dated 3ltt/2021
(designer)
x 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. Strip out (if required) was inspected and the soils
were found satisfactory.
I 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. Strip out(if require )was inspected and the soils
were found satisfactory.
I certify that the system referenced above was nee with the terms
of the RA approval letters(if applicable) 'k 0EF �s�q
CHAP ES �yG
{I -r's gnature) a `'-gig
�FSSONAI
- esigner's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE RILL NOT BE ISSUED UNTIL .BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Scptic\Dvi,g=Certification Form Rev 8-14-13.doc
Town of Barnstable
Inspectional Services
iARNSTABIX ; Public Health Division
Thomas McKean,Director
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
I, vS 1� jN , a licensed Disposal Works Installer in
the Town of Barnstable, authorize` ���� � �
to act as my agent to obtain sewage permits which I have signed for, and/or pick up
certificates of compliance.
Installer Signat Date: VA cc/)
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Agent Signature: Date: "ila V-9 a
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Agent Telephone #:
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Agent. Email Address: � G
C:\data\OpenGov\Health\Septiclnstaller\Septic Installer Authorized Agent Form.DOC