HomeMy WebLinkAbout0009 BLACK VALLEY ROAD - Health 9 Black Valley Rd. , Centerville _
A = 170 189
No. 42101/3 ORA
O
ESSELTE
1Q%
(D
0 d 0 0
No. _ ! "'`" ! Fee, C�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for loigpooal *p0tem Con!5truction Permit
Application is hereby made for a Permit to Construct( )or Repair( ")an On-site Sewage Disposal System at:
Location Address or Lot No. pa d / a, 2,Y �° owner's Name,Address and Tel.No.
Assessor's Map/Parcel 6ei#,,?flv/lle v�yGe" /( ye
Installer's Name,Addre s,,and To.No. Designer's Name,Address and Tel.No.
7 7/-w99
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder(/
Other Type of Building ,da�Cd_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ® gallons per day. Calculated daily flow w 3a gallons.
Plan Date ' — Number of sheets Revision Date
Title
Description of Soil
Natu,re of Re airs or Alterations(Answer when appligable) Aotell
G e �'vL P•vf h o ds�e v U
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction 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& d e _Signed Date I z-hele'`
Application Approved by -(il� � Date
Application Disapproved for the following reasons
Permit No. 94/P 7 Date Issued 1.�2 - �U l
No. Fee i
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS -
Z(ppYtcatton for Miopooar *p! tem Con0truction Permit
Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at:
Location Address or Lot No. -ock �a �� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
e- #, flvl//e To fce Xaye r
Installer's Name,Address,and TelJ.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 13 Garbage Grinder(W14 f
Other Type of Building 4L.01 No.of Persons Showers( ) Cafeteria( )
Other Fixtures j
Design Flow / gallons per day. Calculated daily flow -?3,!:�, gallons.
Plan Date fs"'Z!V— Zti Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when appli able) /7Jr
Date last inspected:
i
Agreement:
The undersigned agrees to ensure the construction alydUn 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 s B d o ea
Signed Date
Application Approved by Date /7'/4
Application Disapproved for the following reasons
Permit No Date Issued
t THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Dispos4 System installed( )or repaired/replaced(v7j'on
by Installer Gl�'�T�LG',�f
at 9 l,�/,L' P Y /' (� �`�y'y/i�/ ' has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9�-GV 7 dated /� '/D -9�
Date j']�-20 • 9 Inspector l
ka y-e �..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
———/—/ —————————————————————————- /—————————
No. /�(O " ���-/D Fee
i
THE COMMONWEALTH OF-MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
;h6po0al *pgtem Construction Permit
Permission is hereby granted to
to construct( )repair( 1/)an On-site Sewage System located at No.# Mlri . Z47 /� % le,
!��!�/t� Sueet
in the above Application for Disposal System Construction Permit.
and as/described `
PP P Y
No. Date
ns or special conditions.
The applicant recognizes his/her duty to comply with Title 5 and the following local provisioions.
All construction must be completed within three years of the date below.
Date: Approved by ( ✓1�1 �� /!� `�b�- s L l �S
Board of Health /
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)
hereby certify that the application for disposal works
construction permit signed by me dated / 7/1101f7 , concerning the
property located at 9 lord' °le rG�'- G Ave-'// ' meets all of the
following criteria:
Y There are no wetlands within 300 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic stem
/ P P P p Y
�f/ e observed groundwater table is 14 feet or greater below the bottom of the leaching facility
'ere is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED: DATE: /O
/W
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
EslL4f� hTa •
t M6tLE rAMUca(• 3 B G 7
tjo C g � C MS 03• I -UN
VL
-
U p •495C�P� �1 "',N
spO �Ac.L41U S�Pi1L�K _.. � I•���r�.''_. 1 �
�pC�- usr � ►.�o�-►�T h nerve/
Fvrl � 7 3s t
AtEJI r two SP
co
m
s�att � 1G
�19� , stESFxv �i+�K
Goss:
SR 0� t•O : Sa G� 44 �r 1 :PIT
�tTy T:Low: 42 �
c. "per LACo w T H.
{
cau�-ria� 330 -:� �.
/ PETER
. .. R(CAARD SUf Ll11A ��T�
BAXTEA No. 217'
��I c Ft• 4
(: b `- T E 4
v �4 52.0 0
497vc-
JODa �s1; 5c �, f4pq ••e
INV. 4y.51NY G�1, �' INS/ 5�•C
a P 11, INY49.8 ;••. `
sic
��I� 11or ` 11JY4g11�Y49.4
C ED PLa
t �. EL T AN
g• g�TtaN: LF
o:."
A�-A DA-rF: LLl1C-S 1`1
LOT ��to
�Y5 w {overt= SHawt�1 RE�tsT ?E� NYE, lK<
T-M 5�a�>_1rJE e.tvl t_ sy���YaRS
�15�I ZMsN-rs �.�1 E ZJS _
"c'tizij'tomE F- do7. ��YI LLF-W-
4-
MA CC •4LA1�
Anl t 5 NUT'3A5t
SuRYCY AND THE A ON AN IN5
» � • ..,. - OFFSET RijM�NT
JQid43�i*► ,,4.. BE USEp Ta 'SHoyyN SHdul� 1`14�'
$L15H'
IUWN Up 13Ai(NJiAliLE
LOCATION 9 �IQG� �0 � rGC SEWAGE # 9�•6y 7 ._
::VII.LAGE ASSESSOR'S MAP & LOT17�
'.-INSTALLER'S NAME dt PHONE NO.�Q/J�� ���1% 771
<.;..*SEPTIC TANK CAPACITY Oo0
LEACHIIIG FACILITY: (type) �� / �� (size)
NO.OF BEDROOMS 'f
9:UILDER OR
COMPLIANCE DATE:
;.PERMTTDATE:Al—/O
'.Separation Distance Between the: -
Ivtaximum Adjusted Groundwater Table and Bottom of Leaching Facility�.�
f Feet
0"ivate 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(If any wetlands exist �/ Feet
within 300 feet of leaching facility)
Furnished by
p
00,
r
� J
L TOWN/ OF BARNSTABLE
LOCATION �9 ,�lQ�1G j0��/�Y / SEWAGE'#
VILLAGE Cie, J�iPf/%�l� ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. � ��1c�✓ �7l"�J��
SEPTIC TANK CAPACITY c% L
LEACHING FACILITY: (type) �� BcJ (size)
NO.OF BEDROOMS y w
BUILDER OR(�/� YZ'
PERMUDATE: I Z I®"Qv COMPLIANCE DATE: ey
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility._ Sf Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) A117 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) e 9 Feet
Furnished by
f
72:4q
nj�.uJ
ia�9a/8 6
No.. ......�.. Fps... ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
/' -....................OF...... . .--.---••------------•----
ApplirFation for Biopoa al Works Tomitrnrtion rrrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
syst......... --.... ._. . .•-•.��'--------------------•. . ------•----------------------
ocati - ddress Lo
-- . ( ..!
Oer Address
ar/t�t.��i�. ._.._.-.-----------------------
Installer Address
Type of Building Size Lot__ _ ------- feet
U Dwelling—No. of Bedrooms......... ---------------_----------Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtu
Design Flow......� -----------------------gallons per person per day. Total daily flow............ -------------gallons.
� Septic Tank—Liquid'capacity4.6"gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..l0_y-�.-..8_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-_-_-.--__-_________--.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 --•---••----••--••---•-•-•••••--•---•••--•-•--••--••-----•..............•-•--••.........•--••--••-•----•-•-•-•---•••••............•-• .......................
ODescription of Soil.......................................................................................................................................................................
W
U --•••••••-••••----•--•----•-•-----•-••---•-•-•--••••••-••••----•••••••••--••-------•-•---......•••-•-••••-••-•-•--••--•--•--••---••--••-••-•---•---••......•••.........................................
x ------------------------------------------------•-----_.
U Nature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________•-----•-__.----.
-----------•---------------------------------------------------------•-----•--------------..........----•-------•---------------•----------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sew Disposal System in accordance with
m-rmx—�
the provisions of i T t!Z- 5 of the State Sanitary Code—The undersign rtljer agrees not t4plac he system in
operation until er --sate of Compliance has been ' ue by thNW
--••
r
Date
ApplicationApproved By.................................................................................................. -•----------•-•--•----•-----------------
Date
Application Disapproved for the following reasons:...............................................................................................................
-•.......................................................................................................................................................................................................
Date
PermitNo. -------- Issued.......................................................
No.. ..........3 F>$...-'�. ........._THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEAL77H
s :`fir e-c---------------OF.---
Appliratiun for Disposal Works Tonstrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
.t
y l
.:. � ................��... .....�°...!......................... ..........`�4 ........-----
a,.�ocattfin Addressr or Lot IQo,.+
f ,P
jr-
................... !� et.;__-_�`C?r.:!te �r:.-P + ......--------...------
�+ 07er Address
Installer Address
UType of Building Size Lot_--------/. . ...Sq. feet
Dwelling—No. of Bedrooms............ ............................Expansion Attic Garbage Grinder (A-)'c,
114
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtu s .---.....--••••......--••_....
W Design Flow...... ---------------•--•----gallons per person per day. Total daily flow.............
..............gallons.
1:4 Septic Tank—Liquid capacit/t. kn.gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—NTo..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
;, Depth below inlet..................•. Total leaching area..................sq. ft.
Seepage Pit No��a._ ._ ;,.a.. Diameter____________________
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-----------------.____--
(X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_____-_-__. -___
•---•---•--------+----------------------------------------•--......--•-•-..................................................................
...--------------
Descriptionof Soil........................................................................................................................................................................
W
UNature of Repairs or Alterations—Answer when applicable-
•--------------------------------------------------•-------•-------------------------•-....--.-----••••---••-•-•---------------••----•••---•--••••-----•-••--•-•-•-•-•-•-•-•-•-••••--••...••-•----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of l i-L_. 5" of the State Sanitary Code-The undersigned6rther agrees not to place the system in
operation until Ce ncate of Compliance has been suea by the bard of;health.
.. Date
ApplicationApproved BY.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:---•------------------------------•-------------•-••------•---•-•-----•-------•------------•••............--.._
-----•---••----•---•----•-----•----•-••----•----•-•--------------•------------.......--------....._..---........--•--------•-----------•-------•-••-------------------•--••--------•--•••••••----•-
Date
PermitNo....................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
�.' BOAR F HEALT
......... .......OF ......... .........................
(9rdifiratr of Tomplitanre
THIS IS E FY t t v>.dual Sewage Disposal System constructed ( or Repaired ( }
by ------ ------------�i1---------------------...------------------
nstaller
at . -
has been installed in accordance with the provisions of i� isJ j of he State Sanitary Code as desc• ibed in the
application for Disposal Works Construction Permit No.._._�'_b__.-4.3.�........... dated------_`�_"_.��____��
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............. t -.. ........................... Inspector........ .- ....................
THE COMMONWEALTH OF MASSACHUSETTS
�..� BOARD HEALT
... . .... ...
1�0,. FEE..*7.!r....
0- I Works T-1onutrnrtion fermi#
Permission is hereby granted••. .........()-Vvr......1......................................................................................
to Construct ( or R�gir ( ) an Individual Se �a Disposal ystem
street
as shown on the application for Disposal Works Construction Per it No.alj.._�3u Dated
-....._L__�.�..._..... �?...........
.......... ....�'..-•-••-. ......... it/t .
-•••--••--•---•-•---•••.........................•.. ~............... Board of Health
DATE. .....---..
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWN OF BARNSTABLE
,v r : � W - J
LOCATIOI���cs�� ���—� U�t�5-�' SE AGE
VILLAG ASSESSOR'S MAP & LOT /70 I
INSTALLER'S NAME Sk PHONE NO.eP, OVR
`�SEPTIC TANK CAPACITY Yi k'
ct LEACHING FACILITYAtype) (size) I
Q�NO. OF BEDROOMS=_PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER d&A) S'HA l
DATE PERMIT ISSUED:
DATE .COUPLIANCE ISSUED: 2 " r 7 D
VARIANCE GRANTED: Yes No c�
..
( ^
�)
� � ��� s �
�� _
�� ��'
�_ � -�' N�
��
,.
y
V E5161%a RTA
51>Jtit i-,ar11 c.�(-3 3E:prJAWVt.5 :v
Ala Cfra � G-r>zfia >'. (U\J n, N
LOW-. I a x3 33D6L?i]
S CFMCT _1K s 33D n%Sog g9sC,P'o - r
it
tl £_ 1 oars 6rA LOU St ec►aiJfC v\ �!r
j7fsYosA'L'PtT--- us F_ fcaa*F.za,f,.iou ►err _� � D
�1t�1-i 1' GQl.15f�G'p '6TO1•lE~ 7 �' 1
sr-
e iA.CCN.%SOSF0,?.5= 37sG?D ,�-
5 A rY_
T3o= RE5 12v L,PIT
sasF 4,
r-wA4cr<•cost= t.v : sa C�Pa b,�x
`rcTAL ID=6 t 6cki 'FLo v/s 425 Ex?P v
33 o E . ",���.�
�'1 �.KCAIATIa�JT1:a �`Vst04 t►.l1�hpLr � ``� '7�•c ��_'L°
F7-H
P
/ TAR -K 1� �C .C�
- FcSCf{3RD. SULLIVAN
A. =� U i No. 29733 1 d
BAXTER
tt '1 `
-Z3 85 ► f.00 't::d 717 of FuE7�?'?
1.7= J,
Z L : SGIL 49 0� 1027Z2 4"^f�!GPi-sr. rf'!
ro04
49.0
N 1.. [.H m W'V S roc
M FTC IUJ491 fN�1494 TAUK
C ERTIFI E.D pL-07 AN
43.0
EL LoC1�Ttz�N: iv"rt .Y�l _ C�
N 8.
fa.o 3Ro...;. :..
'')-ATl
1,JP 71T1= ZYILL.
i cE>z-r1FY Tt-lf'c`r'T4Eu �G .sHz7wt,1 ���ts'�R�� ty-� su �l �-RS
ia-f�JE2;'w
��� ��`i'�A�C -Ei1=c�u��t�41✓ra-rs �F-c�-t E �g��� �.�.�.�-- t�lh� ,
'.ov�l�.1 �F E3A 55 8Li= A LM 15 �10 T
_t:>CA7M3 W1TVAIU'ft' E _F'L-zX97PLA,.)Aa. THis R.Ati 15 K�Si' 3A5tp DNAN 1NST1RtJM Nj
(, SuKVEY AND 1 HE OFFSEf'S SHO\gN 5HZ)ULp T�I4T
_"F usE=� Ta ESr&.T3USH Lz:;rT' L)NE S.
y d9c�4d48;"irk ,rk.,