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Home My WebLink About0015 AUTUMN DRIVE - Health 15 AUTUNN DR. CENTERVILLE A= 168 004 llll UPC 12534 No.2„� 153LOR HA;TINQi, YN �J�, �� Town of Barnstable P# Departinent of Regulatory Services Public Health Division Date A d �1" A�� 200 Main Street,Hyannis MA 02601 Date Scheduled (� l Tune ` Fee Pd. 6 Soil Suitability Assessment for a e 1 ul C Pafbnrwd.By: L • L.y e,. S. Witnessed LOCATION&GENERAL INFORMATION Location Address `� �.iTti'+`� �J.L Owner's Name Address Assessor's Map/Pamel: 16"1 004 Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) <S `/�y 9L,� Surface Stones Distances from Open Water Body 4 1 0 Possible Wet Area ft Drinking Water Well 4_L6_fk Drainage Way I�6 _it Property Line 1� 0 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands Sn proximity to holes) 0 1� -4 i\0' Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: 4�3 A Weeping from Pit Free Estimated Seasonal High Groundwater DETE MIA)TION FOR SEASONAL HIGH WATER TABLE MethodUsed: In. Depth Observed standing in obs.hole: In. Depth to s911 Moines: Depth to weeping from side of obs.hole: _- in, Groundwater AdJustmentAdj.Groundwater Level,� Index Well# Reading Date Index Well level AdJ.thetot',., PERCOLATION TEST Date p....__ Time---- Hole# ton Time sit1,t 9 H — Depth of �L V P Time at 6" Start Pre-soak Time @ °rf,� -- Time(9"•6") .--- End Pre-soak 6 Rate MinJ[nch `"" �'a` 1V Site Suitability Assessment: Site Passed Sige'Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back --- ***If percolation test is to be conducted within 100,of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:iSEPTICIPERC FORM.DOC DEEP-OBSERVATION HOLE LOG Hole#, i from Soil Horizon Soil Texture .Sdil Color Soil• Other Depth Gm) (USDA) (Munsell) Mottling (Stricture.Stones;Boulders. Surface DEEP OBSERVATION HOLE LOG Hole# �.. Depth from Soil Horizon Soil Texture Soil Color Soil other from Surface (USDA) (Munselq Mottling (Structure,Stones,Boulders. e %amyro All . DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil o�ex Surface(in.) (USDA) (Muusell) Mottling (Structure,Stones,Boulders. COT iste O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other ' (USDA) (Munsell) Mottling (Structure.Stones;Boulders. Surface(in.) Flood Insurance Rate Map, Above 500 year flood boundary No— Yes- Within 500 year boundary No Within 100 year flood boundary No_ Yes Deiith of Naturaliy Occurring Pervious Material in all areas observed throughout the Does at least four feet of naturally occurring pervious material exist area proposed for the soil absorption system? Le -Z . If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required traini I&expertise a experience described in 110 C'MR 15.017. `' �. �•.; Date_ Signature s ' 'J" l< q.\sg R'►CIPERCFORM.DOC 1 r- n 4 No. �` // Fee�✓ v d� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zippitratton for Mtzp al *p$tem Con.5trurtton Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) Xcomplete System ❑Individual Components Location Address or Lot No.IS �UVK �r�r2 Owner's Name,Address and Tel.No. Assessor's Map/Parcel (i� Ccr cj e-- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 4 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 1 7&W//�� P`�IC ^ Type of S.A.S. 4 ' C i Description of Soil i4La= Nature of Repairs or Alterations Answer when applicable) s�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 En ' �ndnot to place the system in operation until a Certifi- cate of Compliance has be Signed Date Application Approved b Date 0'- ' f Application Disapproved for the following reasons Permit No. Date Issued �' No. � • F, l � i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSFTTS Application for �Digaal *pttem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) Womplete System ❑Individual Components s Location Address or Lot No. A Owner's Name,Address and Tel.No. Assessor's Map/Parcel 4 Installer's Name,Address,and Tel.No. Designer's Dame,Address and Tel.No. c Qr� Vol V�,_t a 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 'Z ~ C) gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank l SOW �,i C Type o S"'A.S. ( i I nn c Description of Soil 14&9.K... S-Ag J ?i i Nature of Repairs or Alterations(Answer when applicable)_T S0) V—�5C>� r 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 E 1 and not to place the system in operation until a Certifi- s cate of Compliance has be / Signed Date Application Approved �- . .! ?, . Date Application Disapproved for the following"reasons t Z J t, Permit No. D to Issued) THE COMMONWEALTH OF MASSACHUSETTS • BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that tjie On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(� Abandoned( )by , < W t C, at U-T Wl C t vt has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. i dated 40'---7—.00V Installer i' Designer 1� i - r The issuance of this permit s all ot.b ed�tstrued as a guarantee that th s stem will functio as des gned. t' Date Inspector 11 1, � �,f t --- — -------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ' Mi5po5af *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade Abandon( ) System located at '� AL,TL—(Nl. Y 6 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 oft ' Date: �� Approved l/ti/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) I, hereby certify that the application for disposal works construction permit signed by me dated �'�� , concerning the C property located at _�ACJ% /Zt ��yw—� meets all of the following criteria: LZThe 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 There is no increase in flow and/or change in use proposed There are no variances requested or needed The bottom of the proposed leachingfacility will not be located less than five feet above th ty e ma�dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor ethod 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 maximurn adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 5 i B) G.W. Elevation 1�. +the MAX.High G.W. Adjustment.i•u DIFFERENCE BETWEEN A and B 33 3 SIGNED : DATE: e9 (Sketch proposed plan of system on back]. q:health folder:cert O °v f TOWN OF BARNSTABLE LOCATION SEWAGE # VU-LAGE l7 S%��i'�/�p --ASSESSOR'S MAP & LO .4- 4 INSTALLERS NAME&PHONE NO. /I7rA�n SP/O ,r SEPTIC TANK CAPACITY /Se CJ LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 BUILDER OR OWNER ! PERMTTDATE: COMPLIANCE DATE: 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 o II " I ! 1�I iQ �1 L ' II i ! \ I 1 i � 1 i s ! i 1 'I li IN Ii i 4 n i IL i I 1 E ,�.!� '- 41_�:-�l -�_ 111II lii �II�I III, �r •r 'III � I IIII, :I�!!ill!1 I j_.�_.II•-y1.!-�, -!-'I � ^I- ilu!I ' ;j: I t i' 1��' �,�: � I I,II: I 'I�,�� ! it id I.I,,.j I �, � � I r' O 1 h— I 3.4" 8�080P. m • • i1 - --� _._ —_._-ter _ .... ........ 2 F � p T s` I i 4 : I_. .._.._..._.16�4'^__—._____._.... 3-0'• I2•q� � � i II II�I ':8_DRaP_ i � �I I T :'�-I'It'S I_ �i li • II it I ( i I I I 1 _ �t i- I lo• �{ I I� Tr i i illl � 1J1� I II 11 1 11 1•i I I ; 1 li � I.I � �4 t l � 2 IZ.�PIASg� 0 0 I iPA R _t io,0.- J to io —_ N � N @@ A 1 i L I n I I' (pr4 n I N '•i I j i 9 � o• i I � V I i i j n