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HomeMy WebLinkAbout0420 BUCKSKIN PATH - Health 420 Buckskin Path Centerville A = 192 125 No. 42101/3 ORA e Fee (K 5 n THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplicatiou for ]Diopogal 6potem Comitructfon Permit Application for a Permit to Construct( . )Repair(X )Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 420 ,>�.ic�cs�Cin Path Centerville Don DeCosta Assessors ap arce r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. WM. E. Robinson Septic Service Dan Johnson P O box 1089, Centerville. 804 Main St. , Osterville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 n gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title subsurface ewaclP di snnsal s)jstPm Size of Septic Tank Type of S.A.S. Description of Soil z coarse sand Nature of Repairs or Alterations(Answer when applicable) replace failed s a s with 2 leaching drywells ( 25L X 12W X 2H ) 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 by tlu's B�atd ealth. S i g n e / " Date Application Approved by Date Application Disapproved for the following reason Permit No. Date Issued { , ` - THE COMMONWEALTH OF MASSACHUSETTS ( Entergdn computer: ✓ " r� » PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS` ` =r, + Rppficatton for �Bigaal *patent Construction Permit f Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 420 BuMskin Path Centerville Don DeCosta Assessor's Map arcel Installer's Name,Address,and Tel.No. t Designer's Name,Address and Tel.No. WM. E. Robinson Septic Service Dan Johnson P O box 1089? Centerville. 804 Main St. , Osterville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 31 Q gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title subsurface sewage disposal systern Size of Septic Tank Type of S.A.S. Description of Soil coarse sand Nature of Repairs or Alterations(Answer when applicable) replace failed sas with-2 - leaching drywells ( 25L X 12W X 2H ) 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 issue by tlu�oard Health. Signe r i a /7 Date Application Approved by I _ Date Application Disapproved for the following reason Permit No. '� Date Issued - - - � - THE COMMONWEALTH OF MASSACHUSETTS DeCosta BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( Upgraded( ) Abandoned( )by WM. E• Robinson Septic Service k at 420 Buckskin Path, Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a aJ 1 -0 a( dated / i ki-_7 WM. E. Robinson Sr. / Installer � Designer Dan Johnson The issuance of�th/i p rmit shall not be construed as a guarantee that the system will function as designed. Date L ray Inspector l N- .p � _ ----------/'�/�—.—------- --------------_ ————— 5 No. �V//� // Fee ]]]��� THE COMMONWEALTH OF MASSACHUSETTS­_ �- PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS DeCosta Migaal *p!tem Construction Permit Permission is hereby g t t�d tL3UCKt3lScirl 1 Ra p ;( C)Ujgerade j l)AAbandon( ) System located at t 1� 1 Y 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&pe Provided:Construction must be mpl ted within three years of the date of t Date: Approved by r TOWN:JF BARNSTABLE ''P_'iON 'laU LckSkt,'J ?A�L SEWAGE # ad©�- UU(n VILLAGE C�►� �-V t I 1 rc ASSESSOR'S MAP& LOT AZ- 125' INSTALLER'S NAME&PHONE NO. fZO i N S 6 IV SC 12i k ` ? S-8-7`1(o SEPTIC TANK CAPACITY i vUc LEACHING FACILrrY: (type) oZ 'D U`W(A\� ��G (size) 9)(1ZY R NO.OF BEDROOMS 3 BUILDER OR OWNER DE Co SLA PERMTrDATE: °a"` COMPLIANCE DATE: 1 I t (I®'a Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 f <<sk Ptt� E I I a Anck- o up#m i yu � q0 _ o _ r r • � SRS/ot NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM J hereby certify that the engineered plan signed by me dated _ i�9 o,2 , concerning the property located at meets all of the following criteria: This 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 fate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation (using GIS information) -� B) G.W. Elevation 3S +adjustment for high G.W. -0(""*� = 4 3 DIFFERENCE BETWEL -A and B /9 SIGNED : DATE: NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. a q:health folder.percexmp TOWN OF BARNSTABLE LOCATION y (3�C�C5�2d'V �I l'�� SEWAGE # 00(a VILLAGE Cc-- +U.V t i F ASSESSOR'S MAP & LOT—AZ-2- 1 z5' INSTALLER'S NAME&PHONE NO. RO'P i O S G/V 571C-121 k, 2-2 S SEPTIC TANK CAPACITY k v0C.? LEACHING FACILITY: (type) A2 T�2v wt-1\� SDf)G (size) x i2f S NO.OF BEDROOMS 3 BUILDER OR OWNER TEE C6 SL04 PERMTTDATE: I©a"` COMPLIANCE DATE;• ®a Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 I. ± c u f O � 0 r r p , '• WN OF BARNSTABLE LOCATION � 1� /�.� -!� .� i(.� SEWAGE # VILLAGE v . 1L� ASSESSOR'S MAP & LOT - J dLdL INSTALLER'S NAME & PHONE NO. � �oj 22i b 6 :YY SEPTIC TANK CAPACITY J6 LEACHING FACILITY:(type) L�/fe-9k, NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r C✓ v Fy-0,-,