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HomeMy WebLinkAbout0165 BUCKSKIN PATH - Health 165 BUCKSKIN PATH, CENTERVILLE t A = 170 066 • MIi��itt�,YM w��66 No. � l 7 / s' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Migozal *pMem Cow6truction Vertuit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) D Complete System 0 Individual Components Location Address or Lot No. Jd5 Owner's Name,Address and Tel.Yo. Assessor's Map/Parcel G&if/e/ ll le Installer's Name,Address,and Tel.No. /! Designer's Name,Address and Tel.No. 7 7/-Q,Vjf Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures a Design Flow 1169 gallons per day. Calculated daily flow �/�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank bre Q e- "i625 Type of S.A.S. 2— '3 fig' ///0 Description of Soil: • Nature of Repairs or Alterations(Answer when applicable) 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 BQardqf Health. Signed Date Application Approved by Date T—/3 Application Disapproved for the following reasons Permit No. Date Issued 3 2 TOWN OF BARNST/�LE LOCATION l ��G,�S.�IdI Ga'' �/ SEWAG E # VII.LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. AP11V6111 SEPTIC TANK CAPACITY /o,1V G,,C LEACHING FACILITY: (type) Rv G"I l�ety llra���� (size) ail•f ,c�f A?' NO. OF BEDROOMS—_I_ BUILDER O OWNE� �✓ PERMIT DATE: 13—�C� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Sf Feet Private Water Supply.Well and Leaching Facility (If any wells exist on site or within 260 feet of leaching facility) r� Feet i Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by_ if,,r ---------- _.__ i f56/ .Jd' - i- i _sh � I vt ov1 �S ar>� No. � /7 a Fee ✓ 100, - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 21pplication for Miopo$al *pgtem Construction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) El Complete System eindividual Components Location Address or Lot No. /��-,(/� /f� Owner's Name,Address and Tel. o. .,��ilsar! Assessor's Map/Parcel e elbl//le Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. . 9 Type of Building: Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder Other Type of Building J ewk:5�e No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 11 D gallons per day. Calculated daily flow 3 30 gallons. •.4 Plan Date Number of sheets Revision Date Title Size of Septic Tank /,Wa 4f _e2i1,511Wi Type of S.A.S. 2— Description of Soil: J z• Si,'Zit'Z r- Nature of Repairs or Alterations(Answer when applicable) 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 Environmental Code and not to place the system in operation until a Certiti- cate of Compliance has been issued b this B ardqf Health. ► # Signed p Date " a Application Approved by - ally - '`Date Application Disapproved for the following reasons Permit No. Date Issued ---------� --------------------------- THE� COMMONWEALTH OF MASSACHUSETTS /70 -06� BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site S wage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at J`� llG,e �f O)` f,(-/Ile has j2een constr=4 in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _U" /y dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date ' U Inspector --------------------------------- ------ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS =i0po0ar *pgtem onotruction Permit Permission is hereby granted to Construct( )Repair pgrade( )Abandon( _) System located at GAe I-el- 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 e t. Date: ��3�u�� Approved by NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CER=CATION OF SKETCH A;ND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WTTHOUT DESIGNED PLAINS) her ebv ce:aiy that the anpucation ,`or disposal wor.-cs construction permit signed by me dated cone nma the property located at / �r`` 1� G,�6,�'j�'I ,s�'�T�I meets ail of the `ollowina criteria: V/ 7ae failed system is conner ed o a residential dwelling :s oniv. erere a ao ccmme:c:ai or 7us:.:ess uses associated with the dweilinz ne soli is classified as C.ASS _and he oe::ciation ate is less .tan or e;.uai :o f minutes oe:Lnci. �/nere are no wetlands within 100 fee:of the orocesed tic system y 7.-he are no private wells within 1-40 feet of±e orcrosed septic s,,stem were is no increase in flow and/or caanze in ase;roucsed /niere are no variances requested or needed /The bottom of the proposed leaching aclity will :tot be located less than five feet above the mammum adjusted groundwater table tderaticn. "Adjust the —cundwater able using he Fninmcr m :had when applicable; 9♦ ♦ get ♦ s tf the S.A.S. will be located with_.0 _ee,of any ve,_atea we,lanes, the bottom of the pret�o-ec leaching facility will not be located less than fear een(14)feet above the maximum,adjusted groundwater table elevation. Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ° B) G.W. Elevation 3 5:the mAX high G.W. Adjustment. 7°✓ _ 3 J DIFFERENCE BETWEEN A and B SIGNED : DATE: [Sketch proposed plan of system on back]. q.1--th folder.cen 1 165 r�a r f di vase ar1� Je 1 _ r TOWN OF BARNST LE LbCATION l � ��� SEWAGE # J VILLAGE �e n1l Ile ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ��� � �� 7 7✓�3�9 SEPTIC TANK CAPACITY 4 06 o G�f LEACHING FACII.TTY: (type) )U) C&C `W4 f4ftr�t) (size) 1A,S A s- A2 NO.OF BEDROOMS BUILDER O OWNER o PERMIT DATE: i3—Z�W COMPLIANCE DATE: ll 4 mm� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �f 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 ��l l'g ear t,2f' /,qfj No..---•--..........------ Fas ................. THE COMMONWEALTH OF MASSACHUSETTS APFROM BOAR® OF HEALTH ant TOWN OF BARNSTABLE li i uiul Works Tonfitrurtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair (J 4 an Individual Sewage Disposal System at: ----------- -------- Lot Lot ...................f ................................................. .. -•----•-------------••-•----•••----•-••-••--•--•---•---••--..............------............-- " CI drCS nd W L0 /> Oj�� -7Co S �l BCD �! Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures — --- -- - -- ............7_7b gallons. W Design Flow.................___.__...__..._._..__ gallons per person per day. Total daily flow..._.....:..._._...._.......................gal WSeptic Tank—Liquid capacitV�B�B_.gallons Length................ Width---__---.��Diameter_----.--_----._- Depth................ x Disposal Trench—:�,o. ...........•_....... Width.......7...._._.. .Total Length---sw�`.-____ Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY-------- -----•---•---••-••••-----••••---•--------•--•--•----•--•--•-••... Date........................................ Test Pit No. I................minutes 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 V ........•••••-••---••-••-•--••-•--•---•-----••••-•---•••-----••--------•---•--------••-------------•---•-•-••-•••••----•••-•••••----••----•---•••••--••-•••••----.......---•••-••....--------•-••--••---- W •-•-• •---••--------•----- •-------•--•••.......---••-•-••-•------------•---•---------•-•-......................................-••••------ --- U Nature of Repairs or Alterations—Answer when applicable.--� D..................... ----..r //V Chi 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 b en issugi by t board of health. Signed ........... .. ... ----------------- .---------- / s ... Dace ApplicationApproved By ...................... .................................. .. ------------------------------- ---------------------- ................. --------......------ Dace Application Disapproved for the following reasons: ... ........... ... .............. . . .. .... .............................--- .................... ,. L Dare Permit No. ``..............)-!$......r�.........3..................... Issued .................... ........�f ......rj................. M 3 /-70 } 3 No.._. _. � I Fps........ ...-J........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE XvVitration for Utr mial Works Towitrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair (>�. an Individual Sewage Disposal System at: ---------------------------------•-------------------------•--------------------------------...... ----•••-•••--------•--•••-•-•-----••--------...........__...-•----------•-----------...---......•- /� Location-Ad ir s- or Lot,No. ......................_.......................................................--•----•---------- -••-•••------••-•--•••-•----•-•-••-•................••---------••------------•---..............--- - / / �P 5 L 1 Jam'/.c.E. Address f �'/�( Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.....................................................__-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.........._................. Showers ( ) — Cafeteria ( ) a' Other fixtures .--------------------------------- W Design Flow...................5.�l...............gallons per person per day. Total daily flow.._.......-:�-��....................gallons. 9 Septic Tank—Liquid capacity..��A_galIons Length---------------- Width---------------- Diameter---------------- Depth................ 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 ( ) F" Percolation Test Results Performed by---------------------------=-•-•••--...................................... Date........................................ W Test Pit No. 1----------------minutes per inch Depth,of Test Pit.................... Depth to ground water........................ GX4 Test Pit No. 2................minutes per inch/ Depth of Test Pit------------_....... Depth to ground water........................ P4 -•-•-•••-••---------------...---•--••----••---_.....••••---••---•••---•-•••••••................------......................................................... 0 Description of Soil........................................................................................................................................................................ W U ........ ............................................................................................................................................................................................... w U Nature of Repairs or Alterations—Answer when applicable.__ O......... ..... 1 �nJ c�T ;zt/4S !� _ . /. ."..............� i7l�tiJ.. "� �� (5 i i,✓E-...._... 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 byytthe;board of health. Signed ...........//t�t-fn //..-.--1......�. �.v � - /5= .......... -- Dve ApplicationApproved By .......... ................................ . .. ........................................................... ................. .e.................. .Application Disapproved for the following reasons: ------------------------------------------------------------------------------------...----------.........---.................. i ...... .............. ... . ........................... . . ,[� Dace Permit No. ....�� ....... Issued 1. / ---.L.'. ................ Date I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Q-TWErtifirate of (VIT>amplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System_constructed ( ) or Repaired (� ) by .................................................... ......... -- -------- ...................................... Installer at ............... .. .. -- .. ... ......... .... ... . ! ..--------------------------------''- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Cod as described in the application for Disposal Works Construction Permit No. ..._r>��.....-57. _3i........_.... dated 4 3............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........1 ^`.. �-'---.__f.:_�r�...._................ _------ lnspector ......... ......... -..---� -h '............... THE COMMONWEALTH OF MASSACHUSETTS /70 ' 664 BOARD OF HEALTH TOWN OF BARNSTABLE No ....... 3 FEE.. J. Rope ial Workii �,an #r�tr#i�n rrmit Permission is hereby granted.................... 01 i t /!. ....... tiS�r ----/G...1.............................................. to Construct ( ) or Repair (--/) an Individual Sewage Disposal System. ------------------- ------•-------------------------•------•-----•--•----•-•----------•---• --------......•-•--•....._........ Street as shown on the application for Disposal Works Construction Permit N�..-'�� ... .���. _..����?....._........ . Dated .. � Board of Health DATE........ ...................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION '`, U .sSICi�Y SEWAGE # VLLLAGE 4: ASSESSOR'S MAP & LOT/ 70 INSTALLER'S NAME & PHONE NO. ,00t) GAT% F9.)z i r SEPTIC TANK CAPACITY /(!©J LEACHING FACILITY:(type) 1/l!�t��. 0 (size) �• NO. OF. BEDROOMS L"�r PRIVATE WELL OR BLIC W TE BUILDER OR DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No e �V 4A yt' Y � I 77