HomeMy WebLinkAbout0044 CAP'N JAC'S ROAD - Health . -. ...._._ ... _-._._.- .-...
44 CAPT.JAC'S ROAD, CENTERVILLE
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UPC 17534
No.2 1,�,�53C0R 'bs�oo
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No. ! � Fee
THE COMMONWEAL-'H F MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN BARNSTABLE., MASSACHUSETTS
Zipprication for Migpogar *pgtem Congtruction permit
Application for a Permit to Construct( )Repair( )Upgrade )Abandon( ) ❑Complete System )4ndividual Components
Location&ddress p���No. '� �• S Qwner's Name,Address and Tel.No.
Assessor's Map/Parcel M Q1i ( � c Qi/ 0.
/�l�Jf' ( �;J i Vr'
In.sW1er's rr s,an�,T�l.fT;. �� Designer's Name,Address and Tel.No.
G �S 1 /�N947q
Type of Building:
Dwelling No.of Bedrooms T Lot Size ��/�a sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow :?f 0: gallons.
Plan Date Number of sheets Revision Date
Title 1 '
Size of Septic Tank Type of S.A.S
Description of Soil
t r
Nature of Repairs or Alterations(Answer whe applicable.)
Date last inspected:
Agreement:
The undersigned agrees to ensure the con str on a maintenance of the ore d scribed on-site sewage disposal system
in accordance with the provisions of Title 5 of t ental Cnd t to 1 e the system in operation until a Certifi-
cate of Compliance has been issued by t is
ed Date
�4"WAlapro� Date"
Application Disapproved for the ollowing reasons
Permit No. -IF Date Issued � �
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TOWN OF BARNSTABLE
.LOCATION 7�n CW L62= SEWAGE # . 3 y 7
VILLAGE g7wri V/LLt ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. �,Y) gq J"Zen
SEPTIC TANK CAPACITY 1e,:)C20 CPAL—
LEACHING FACILITY: (type) 'fiE EIJC H (size) Z' yO X y X 7-
NO. OF BEDROOMS
BUILDER OR OWNER �� �
PERMITDATE: 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
-
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No. 6✓ Fee
THE COMMONWEAL F MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN BARNSTABLE., MASSACHUSETTS
Rpplication for Mt6po5ar *p5tem Congtructiori Permit
Application fora Permit to Construct( )Repair( )Upgrade )Abandon( ) ElComplete System Individual Components
Location Address pr Lot No. � J S �,(] Owner's Name,Address and Tel.No.
0ly is M p/P c e�-
Assessor's Map/Parcel
I�alter's Namg,A�iress,and Tgl�o. � Designer's Name,Address and Tel.No.
Type of Building: ram, t
Dwelling No.of Bedrooms '` Lot Size 2-0 U s I ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
1119n Date Number of sheets Revision Date
i Title
31 Size of Septic Tank Type of S.A.S�
Description of Soil
5
Nature of Repairs or Alterations(Answer whe applicabl
Date last inspected: 11-71
F=. Agreement•
The undersigned agrees to ensure the cons ion a d maintenance of the ore d scribed on-site sewage disposal system
in accordance with the provisions of Title 5 of t E eta Code and t to 1 ethe system in operation until a Certifi-
cate of Compliance has been issued.by t is
Si ed _ Date '
4AVnaw:x Pro �611owing
DateApplication Disapproved for thens
Permit No. Date Issued 1
———————— ————————— —— ———-—————————K
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, ASSACHUSETTS
THIS I)y0 CE TIFY Whe -sate ewa '"D'i�p�Sal System Constructed( )Repaired ( )Upgraded(�)
Abandoned 6t !v
at has been constructed in accordance
with the provisions ofs i e5 d the for Disposal System Con truction Permit No. M r dated Je� 7
Installer f .ol1/ �� / '\1� Designer
The issuance of this permit shall not be construed as a guarantee that the syste will unction as designed.
Date I,- --2 e Inspector
- - - - - -
No. �' ! Fee zzn
.THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
MiOpOaf *p5tem Cougtructiou Permit
Permission is hereby granted to Construct( )Repair( )Upgrade )Abandon(
System located at J J i LLe
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:Constructions must be com leted within three years of the date of this
Date: _,"? "M Approved b
1
I
10/9/97
i
i
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
i
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
i
1, CN1M5 00ffe'roi ,hereby certify that the application for disposal works
construction permit signed by me dated 6 .1 . * , concerning the
property located at 411�GA?J - Jki's meets all of the
following criteria:
r/ • There are no wetlands located within 100 feet of the proposed leaching facility
v • There are no private wells within 150 feet of the proposed septic system
V000"o There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
/ • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
VVV proposed leaching facility will t=be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 7 V
B)Observe oundwater Table Elevation(according to Health Division well map) 3.S
SIGNED. DATE:
—!or
W.LICENS 'TIC YS Table
IN�HE�OF BARNSTABLE NUMBER
1
[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
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42,0PrrD
TOWN OF BARNSTABLE !' C, 1
WX�01
JQrr-S SEWAGE # 3 7
kVILLAGE CL�AJ7rZVPLLr ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. C6622 csn-b�z
gm L`'
SEPTIC TANK CAPACITY le!)c2® Cy t -
LEACHING FACIL=: (type) ITEN04 (size) Z' ��' y�X Z�
NO.OF BEDROOMS N i
BUILDER OR OWNER
PERMITDATE: OMPLIANCE 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
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oCo os
D
No. r'� 7
r THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
.......OF... .���. rl. ..�-----•.......................
Applirufiou for Diupogal Works Tonstrurtiun thrutit
Application is hereby made for a Permit to Construct (L,4 or Repair ( ) an Individual Sewage Disposal
em
S st .aR....� .. k_.. �.
-• -�� -� = T - • .
• cation-Address or Lot N .
f Own r Address
--
............................. . � _ .11 _(, .. ..
Installer Address
d Type of Building Size -----Sq. feet
Dwelling—No. of Bedrooms........ ...............................Expansion Attic Garbage Grinder (1a)
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures --------------- --------------- -
W Design Flow........�-�-0.........................gallons per person per day. Total daily flow--......�.r.3._10.....................gallons.
WSeptic Tank—Liquid capacity MOC.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 to ( )
'~ Percolation Test Results Performed by.......-r6-fN ................. Date....`-.'../_'. 1.............
a
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----------------------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......---..............
------------------------------------•-------------------------------------------------------•---.....------------.........---------------..........•---••••--
O Description of Soil-o..n_.1.3 ......LKN-_E! .......01�------. -------1��, = =-----�.....R lj.�----------
U ----------------•----"--------------------------------... .4 P�?-------4-N.��1�e_:�--------------------------------------•-----------•-------------------
U
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 TITI.i� 5 of the State Sanitary 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 :" •--------------- = / fit
Date
Application Approved By.............. t........... ?_
Date
Application Disapproved for the following reasons: ------------------------------•----------------------------------------------------------------------•--•..._..
.....................•-----------------....------....---------------------•-------------------------------•••-•••...--••-•••••••-•••••-•••-•••-•-•-•••-•-•••--•-•••-•••-•---•-••------.-------------7-
Date
PermitNo................................................... Issued_.......................................................
Date
No......................... Fizz..........................
_
._ ZA THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�QW.14...................OF..� ..............................
Applira#ion for Disposal Works Tonstrnrtinn frrutit
Application is hereby made for a Permit to Construct �/) or Repair ( ) an Individual Sewage Disposal
S stem at:
?::..... .:�..-- : :V K L.�....._.. �' v c ..... -....--
---u-...---
m ocation..Addre,Ts " I�toL
as -- ............................. .................. ..
er .......-
Ow Add ess
1-4 Installer Address .
.14 Type of Building .3 Size LoU_4D.`_ ------Sq. feet
I-, Dwelling—No. of Bedrooms............................................Expansion Attic 04) Garbage Grinder (10)
Other—Type T e of Building No. of persons............................ Showers
� YP g -------•---------------•---- P -(---->--- Cafeteria ( )
dOther fixtures ...-•-••---•--- ----------•-......------------•-•---.-----••---•-•-•-•-••---•-----------•-••-•-••
W Design Flow.......�I-Q..........................gallons per person per day. Total daily flow_____ .� gallons.
W Septic Tank—Liquid capacityl t..1�'(..gallon 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 ( )
`" �`� Date. - �Ij�.//
Percolation Test Results Performed by-_____.�__ `t f�. ..... ............. .. - .. .(._.__.•.-____...
1 Test Pit No. 1................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 -••--••-••-----•----•--••-•................•••-----•----•...•------•-•.............---------.•-•--•........................................................
,y0J Description of Soil.i..':.I-`-r...--.� (�_��..I -... A_ ....- -(���-- - /•- -I -��----• - ...---- �--'....-P.v 4_E.-•---•----
............................4l-_ _!v. ...� 1�...... es__^._ �!' :_4✓+-..........._.........._.............................--................_
W
........................................................................................................................................................................................................
V Nature 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 TITLE,_ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of hea h.
Application Approved By. ....nt .e.. . ZDge "g,
01,
Application Disapproved for the following reasons:.._.__-'� ...............................................................................................
............................•-------..........--•-----------...-----------...----•--------•----•----------••-•••-•--•---•--•-•-- -•--•-•-----•-•••--------••••-••--••-------•--••---•--••-•------••-•---
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7�.W..o..........OF.......(3..fit- ..r.......................
TntifirFate of TuntpliFancr
FINIS IS TO CERTIFY That the Individual Sewage Disposal System constructed � or Repaired ( )
by----___.�:�':.Q I t 40....----6p._qi,..................------------------------------.........---------------------------.......---------......------------------------.
at . . V
has been installed in accordance with the provisions of TIT 5 o�f.Te State Sanitary Code as described in the
application for Disposal Works Construction Permit No..... .......
.. .... ......... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UE® AS A GUARANTEE THAT THE
SYSTEM WILL FU TI N SATISFACTORY.
DATE...----•-............6..--a._._�..5.................................... Inspector................ -- ---••--•.-------' .._..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�.. ...........................................OF..................................................................................... r G,
G'
No.................�... FEE...-•22• ..........
Disposal Works TWantrnr#ion rranit
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo..................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
, r�
-------------•-••--------------- --------------------------------------
-..........
r----------.----
Board of Health
DATE................................................................................
1
FORM 1255 A. M. SULKIN, INC., BOSTON ��
0 C A T ION �v S E W A PE RMJT NO.
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VILL-ACE
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INSTA LtER'S NAME i ADDRESS
'.- BUILDER OR OWN ER T
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 6
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►�o Ga1zeA�E 6QJNDECZ 2u I i
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s
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5 A A �C,5 5o.F•BOTTOM I
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^toTAti- C�ESIC,N = .42�j G.PD.
-TOTAL. DA I I-Y F%-C>W 330 G.PD, I +0 I Ferro 13
PE2COLATIoN RAT6 � I•�IN ZMIN o>~LESS - i
?v,49 °
cr-OF
f ICHARO
FLAX.,ER
R
loov INV•
LA e► INd. Cv-rC
, i .
`� l0l
BuX IOI,G TANK
of 1000 INS! j
' +PPaa Gba.. /o/-v
I1A c, LCAcu
PIT INV.
F71 W6 wI Tu /o/•Z
�jAIJO I•/3/� I�L
Aw!> WASNGD ~-
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�� No SGAI.E SOALE ('� �' -ATE
Alo K/A M7Z. p L.p.tQ REF E 2E►J GE
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i -TowN AND IS f• t• � iJ ��►�+ 4immd
L.00/6-7rED WITNIQ THE FL oD PLL+.IW
DAT E 1 �-�� 6A.'K+S W YE I N C•
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IuS�uME-I.,J ,uQvEy g� -T nt=FSETS SWoULl�
►�oT laF USE � TO DETER.'^1►.1� l cT �. II.IE-j APPt✓ICAr.IT -1 „f`rj ! /'�E ``• '_�I