HomeMy WebLinkAbout0150 BUCKSKIN PATH - Health .50 Buckskin Path
Centerville
A= 170-070
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pprication for Migpogal *pgtem Cougtructtou Vermtt
Application for a Permit to Construct( ) RepairUpgrade( ) Abandon( ) ❑ Complete System ElIndividual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
i SG 83 4skw, P4 ,
Assessor's Map/Parcel e I���G✓�
1 ® A k,-, 8.4k rn 4 b
Installer's Name,Address,and Tel.No. 09-77L,..(oy(,d Designer's Name,Address and Tel.No.
k C ICU &, 7� S R,*' fl_
Type of Building:
Dwelling No.of Bedrooms f le< Lot Size `Y /:50- sq. ft. Garbage Grinder ( )
Other Type of Building rrsi&fia,) No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33 gpd Design flow provided 35-C)e -I gpd
Plan Date Number of sheets 9— Revision Date ��yk q
Title
Size of Septic Tank &CS bNaf Type of S.A.S. LPgcI%
Description of Soil C cAf5e Sea.,C1 IL /'7r�r`,,�cor-v ,S,6, 5
,
s Nature of Repairs or Alterations(Answer when applicable) 14 ci - o t //tr L
it
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 Certificate of
Compliance has been issued by this Board of Health.
Signed Date C9lo iDy
Application Approved by AW J2 ,S, Date / 2B u
Application Disapproved by: Date
for the following reasons
Permit No. �04�(�- 16 2— Date Issued 2®O�
•, -�f ., _ e� ,,� +moo t. r
i , No.�00�„' /(J� � —r`�6e ;�� 9 # + •i 01
Fee /00
Entered in computer: r/
j THE COMMONWEALTH OF MASSACHUSETTS : Yes
PUBLIC HEALTH DIVISION - TOWN OF' BARNSTABLE, MASSACHUSETTS
Application for 30i!5pogar *pztem Construction Permit
Applica Lion for a Permit to Construct( ') Repair Upgrade( ) Abandon( ) E Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
1 S6 (Bu4skw• P4),, f�
Assessor's Map/Parcel ✓t ' L p q ko✓1
So xksk ,. lie 1-4
Installer's Name,Address,and Tel.No. (j�.7 7 U-Lys Designer's Name,Address and Tel.No.
,�?L•C'• PU fox 7� S 4,4, R�ICer• _D
Type of Building: — E
Dwelling No.of Bedrooms ��/rt Lot Size 1 �S /541 ` sq.ft. Garbage Grinder ( )
Other Type of Building rZ5, • k" No.of Persons '"' Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided_ 3SCJ• 9 gpd
PI 4 an Date Number of sheets y 5k Revision Date / h 3Ib 9
Title
Size of Septic Tank f"S -N"4e
pe of S.A.S. (r4r(� ('1,anpr�-S�.
Description of Soil ('Ina/SC $qh C1 f. oav-2, 56( 5
a Lri
'Nature of Repairs or Alterations(Answer when applicable) rnil4r,o, el- goy- o,d - S�Y►H /l lv3
_ Date last inspected: {_U
Agreement: \ l
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 Certificate of
Compliance has been issued by tfiis Board of Health.
e Signed i Date e, /�y
Application Approved by .S- Date S d
Application Disapproved by: Date
v
for the following reasons
s
Permit No. Date Issued �' s Q
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
at 50 46 A n ti has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Z 00�r' �(j dated (9
Installer X• )?;K,-,, A L•C. Designer T Q. ('a-,V/4n.
#bedrooms ��� S '� Approved des n fldNv 3 gpd
The issuance of thig perm t''sshall not be construed as a guarantee that the system willJ�cNion as dell�1 ned.
Date �a V Inspector ,/(y kr". S
Fee f '
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
1=igpo!5al *pgtem Cow5truction Permit
Permission is hereby granted to Construct ( ) Repair (�J Upgrade ( ) Abandon ( )
System located at 4za �LZAi0 ._911 �t ,s„
f
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 of this permit
Date !c, —/2 0 0 Approved by
i v
e
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
_ r Public Health Division
639 & Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508- 2-4 Fax: 508-790-6304
7
Date: to 2 Sewage Permit# GO 462 Assessor's Map/Parcel
Installer&Designer Certification Form
Designer: I cI/YlW A &Ai d nerw 1T Installer: R.k5e�:- / W4 C
Address: 6AJ Address: )16 &,e
On "Z' icite, Z was issued a permit to install a
( te) (installer)
septic system at /S G gvc „, based on a design drawn by
(address)
• �fjk ftWkv dated I LIS
(designer)
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. 'Stripout (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 R t'ons. Plan revision or
certified as-built by designer to follow. Stripout(if requi t 4 ted and the soils
were found satisfactory. �, q�
o DAIGNcAt 1 „I
(Installer''s Signature) No, 4,095 r
Fr�ST
Ila 1-1 A A
1�
e i s Si (Affix Designer's Stamp Here)
PLEA RETURN BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice formsWesignercer ificarion fonn.doc
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oF�
To
wn of Barnstable r#
Department of Regulatory Services
, s Public Health Division Date
ttu�. A
200 Main Street,Hyannis MA 02 0I ^
Date Scheduled Time Fee Pd,
Soil Suitability Assessment for Se ge is o
By:
Performed By: Witnessed B : O U
1
LOCATION& GENERAL INFORMATION
Location Address I,5) o JG'/,�,/J I� Q 4, Owner's Name
fc.t.7&-
Address
Assessor's Map/Parcel: ��.�o � Engineer's Name Fd/nu/.t b��-�
NEW CONSTRUCTION REPAIR Telephone# _?74 63(0
Land Use o�t Slopes(3'0) ! Surface Stones
Distances from: Open Water Body %A/t 2 ft Possible Wet Area ��J�G) ft DrinkingWater ,Well —ILft
Drainage Way ft Property Line /(P" ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands i'n proximity to holes)
� ��jG Play, f?"r Guam lvei�
04
0
�a
U
3uG�1nl
Parent material(geologic) e�>Q_TV4146 H— Depth to Bedrock +Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face �J A
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABU
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in,
Depth to weeping from side of obs.hole: __ in, Groundwater Adjustment ft.
Index Well# Reading Date: Index WeII levcl,� r Adi,factor Adj.GroufldwaterLevel Ro
PERCOLATION TEST l)gtV 1z Thne
Observation p
Hole# ' Time at 9"
Depth of Pere Time at 6"
Start Pre-soak Time @ 'QC 'lime(9"4")
End Pre-soak
Rate MinJlnch
Site Suitability Assessment: Site Passed % Site Failed: Additional Testing Needed(Y/N)
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:\SEPTIMERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Con istenc ravel
0— 17d
Ib- /to 1b\,ee 3to L . S .
/0 y,e S7/4 CGS
� r
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottlithgi (Structure,Stones,Boulders.
Cosistency.%Gravel)
• DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,
Boulders.
Consi en
N
Flood Insurance Rate Mau:
Above 500 year flood boundary No— Yes
Within 500 year boundary , No; Yes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervioqp material exist in all areas observed throughout the
area proposed for the soil absorption system?
Q S
If not,what is the depth of naturally occurring pervious material? ..�
Certification W��� _ f_
that on t�C,K�I1 ) (date I have passed the soil evaluator examination approved by the
I certify t )
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training, perfise and experience described in 310 CMR 15.017.
Signature Date
t ,
QN\EPTIGIPERCFORM.DOC
TOWN OFBARNSTABLE
LOCATION SEWAGE# `�
VILLAGE ASSESSOR'S MAP&PARCEL 1,70 &d
INSTALLER'S NAME&PHONE NO. Yob 776,"
SEPTIC TANK CAPACITY 1670 Pa/� '
LEACHING FACILITY. (type) 14,' s:iQkn4 (size) P d r—Y6
NO.OF BEDROOMShd��
OWNER L em(I
PERMIT DATE: 61 A61? COMPLIANCE DATE: �J
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility>�. 6 7 Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) 414 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within ��gg�
300 feet of leaching facility) ?!/!7� Feet
FURNISHED BY � � � ,�'�,C,
Pam f Pod,
LLI
oe
�I� YS
No.73-. U FIm..... ............
APPROVED THE COMMONWEALTH OF MASSACHUSETTS
8amstable Conservation Department
BOARD OF HEALTH
2TOWN OF BARNSTABLE
S na!
Appliratiun for Diripniial Wurk,i Towitrnrtiun 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( -7-an. Individual Sewage Disposal
S stem at
• ---- -------- -
:�daress aa
--- I,oCV
W er � � css�"
......
oun.. .
......................... ............
t� ! Installer Add ess
UType of Building Size Lot............................Sq. feet
,-t Dwelling—No. of Bedrooms.__________________________________________Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ............................ No. of persons------------------------- Showers ( ) — Cafeteria ( )
04 Other fixtures --------------_---_----._.__-. _ .
W Design Flow............................................gallons per person 4eyday. Total t y flow.-- .........................gallons.
WSeptic Tank—Liquid capacity1....�.�gallons Length....... ........ Width---.6........ Diameter----............ Depth................
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box f-_ Dosing tank ( )
1--4 Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a --•------------------------------------•-•---------------------..........---•---•----........................-•-----'-'•-----------..........................
0 Description of Soil........................................................................................................................................................................
x
U •-••--......••---••-----------------------------------•----'--'.'•'-•---•'•-'---•-•-"---•-"-----•'•-•-'--•'•-•'-...-•----•---------...---...--•"--•--.-'-"'----••------•------•-•---•--...-----•----
x '•--.........------------------------------------------------------------------------•-•-•.... ................ ....I------------...... =
U Nature Ir or lter s—A sorer when applicableI._� _.- ..___ .
...... .�. -- ----------------- ----------•........---------------------------.-•----------------.---......--'-....!............_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ,
the provisions of TITLE 5 of the State Environmental Code — he undersigned further agrees not to place the vim/
system in operation until a Certificate of Compliance has been i ed b e t
Signed ............ - - - ...................... . .....J ` .`.` .-..
'`^�-� - Dare
Application Approved By ------- , V ......._......._........... ............................ . ------�1:.
Dace
Application Disapproved for the following reasonr: ... ......................... .. ................. ........ . ............ ---------------------------
.........................................................,...................................................................................................................................................... ........................................
Da'
Permit No. ........q/ &Z--,W. .............. Issued ..... . ............................ ---............ .
Dare
ly a.r�> ••1„�_.`.+w�-+�•�••� �e:.«.,.� ,..-. �..ti.. _._..__.,` .--..--..-.�.d;S-�.. �"-vti-......_. ... . ..-..�..- t.,t..-•......._. ,`..... ......-3a .a._..-.�... �... ti�+-
FEs...... ............
THE COMMONWEALTH OF MASSACHUSETTS
= BOARD OF HEALTH
-'TOWN OF BARNSTABLE
Apphratiun for Uilipniul lVurk.5 Tomitrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( -)an Individual Sewage Disposal
System at:
014q k,.
-- rc�r1
or
,02_01,Liftt..n---\ddn... .. �_.....C_ _K !zi.41 F l��__. 1�7C /-� )t_•ll_
• O++ncr d'dress
a PYt7a,n.Pio_01 �1�1Y( C/Lt._C1!?.:. ........... !�C_ /.r!, ._ :_ _� - �
14 ! Installer ! ---- -
go
Address
VType of Building Size Lot.................... Sq. feet
.� Dwelling—No. of Bedrooms.____ ---------------------------------Expansion Attic ( ) Garbage Grinder V-6)
aOther—Type
of Building -.--.---_----------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures --------------- •-------------••-•-•--- --••--•--------•-----------------•-------- -----•---•-----------------------•-----------___._-_--._----.
W Design Flow............................................gallons per person per day. Total daily flow.._ ' ........................gallons.
WSeptic Tank—Liquid capacity)C gallons Length.-.-. ------- Width....---------Diameter---------------- Depth................
x Disposal Trench--No- -------------------- Width•-___-.----..-._-_-- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet........._.......... Total leaching area..................sq. ft.
z Other Distribution box (—^"`)" - Dosing tank ( )
14 Percolation Test Results Performed bY.......................................................................--- Date........................................
W
Test Pit No. I................nunutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----
•----------------------------------------------------
•••--------------------•-••---------•-----•---
•-----
•....
_-•••.............
_...
_................
__..
0 Description of Soil........................................................................................... ------------....----------------------------•---------------•-•----------•--
x
U --•--------------------------------•-------•---•---------------------------•-----------._......----------------------------------...------------------------------------------.........----......_......
W
x ................
r � .
.--Natuf pairs or lterati s—Answer when aPPlicable-)t5 (!_/
..........1:-• •-• ....
.. _..._
-!--..------..Z..--- �V`_-i------------------------------------------------------------------------------------------•------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the-board-of heal' .
Signed .......... - ��- k.._ ..-.... .-r��" ....
Dace
Application Approved By ......... ,. .. 1...��r._�� , ...._... �/I.....-. .�!. ....
Application Disapproved for the following reasons: .................... . . ..... . ................................. ..................... ..............................
....................................... .............................................. ................................. .... . . ................................-- ........................................
Dace
PermitNo. .... i...,(5............... Issued .......... --........................-- ..................
Dare
.—_._.---- —. .-- _-E--- -...--_._. ---------- -----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
llErtifirate of Compliance
THIS IS TO C TIFY That the Indivi•ual Se age Disposal System constructed ( ) or Repaired (-- ---)-
b ------------------------------------ ,! /......-.-i^...0. .._..... - _......... .......- ..-..
at ............................. �.S.Q 11�,�� L/ 1 A/�--1`-1 ... .......CC11�/--- ------------------------------------------- ---------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..?.,?_....&I S..<<2........... dated ..........._._-_......_...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ ............), � _ --- _................................
__----_------- --—----- --_- _- _- -_----�T��__ -------_.---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No._.`!_. _.-,/�. _ FEE.....� !�
Dispiastt9rkii "Jaanotrurtinrt Vlerntit
Permission is hereby granted `! `���C ��l =
to Construct ( ) or Repair (/ran I divi�lual Sew,�e Disposallyst (A /�
at
Strcct
L�
as shown on the application for Disposal Works Construction Permit Na9_1.43_.?. Dated........t. - ...L�_.-..1 ..
�
DATE........... _-_ ..!.c......t?-,..................................... Board of Health
FORM 36508 HOBBS R WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
LOCATION t50 /�����LQ.� 4�1� � SEWAGE #
VILLAGE ,, - i—�Odj
ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.Jb6ef6fXV
SEPTIC TANK CAPACITY 10D
LEACHING FACILITY:(type) OL (size) -
NO. OF BEDROOMS �- PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: Ll - q 3
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No c
VI
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