HomeMy WebLinkAbout0042 CROSBY ROAD - Health r
42 Crosby Road
Centerville
A= 229 — 128
S M EA D®
No.H163OR
UPC 10259
smead.com • Made In USA
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No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
OFwV �l'4�'Gd `♦
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1.-:L
APPLICATION FOR DISPOS SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( Upgrade ( Ab nd n ) - ❑Complete System ❑Individual Cot ponents
GWOO V`-`�)ifuq(4q, , s- 1
Owner's Name r��
tap/Parcel# Address
�—
VV��--�� DooesAA igner'sName
dress p �F� � �—
ress
6
elephh-one#
F Telephone#
Type of Building: Lot Size q.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures �
Design Flow(minj re uired) gpd Calculated design flow gpdCate
esiYT gn flow p ov' gpd
Plan: Date Number of sheets Revision
Title
Description of Soil(s) QUAA Gc-lo1
Soil Evaluator Form No. Name of Soil Evaluator - Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agr es toKsta the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furthe s n t to pI fe the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ate
lUV
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
C?0/� i
NO. THE COMMONWEALTH OF MASSACHUSETTS FEE I
BOARD OFF HEALTH J.
r ;
APPLICATION`O DISPOS SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( Upgrade ( Ab ndo n ) - ❑Complete System ❑Individual Com1onents
Kati Owner's Name `"
( GG ..J `LYE/ zj1
rap/Parcel# Address
b
C! t" i�Lot# Tel e# f' , ✓�9\
Caller's am Designer's Na�me�(—�j`/��t�
ddress AMres`•'s
Z
Telephone
c Telephone#
Type of Building: i:fFb)Pf%_ `1 n`✓ Lot Size q.feet
Dwelling—No.of Bedrooms �'� Garbage Grinder
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures __----•--_
Design Flow(min required) gpd Calculated design flow gpd i 'D sign flow p ov' e s gpd
Plan: Date -Number of sheets Revision Date
Title K /
1 '
Description of Soil(s) A OLAA "-COI�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation ap".
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigneid"cgr s to�ifistal the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further g s not to pl a the system in operation until a Certificate of Compliance has been issued by the Board of Health.
,Signed ate n
�peudoos v
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORK 5/96
No. .� T E COMMONW LTH OF MA$,SACF LU,S19TTS FEE ML JJ'
BOr�41RD�O-H�ALTH
CERTIFICATE OF 4q� OMPILI-ANCE
!� 1p 'e t"(%jl P
i Description o ork:...�•---` RdlVldual Components) i �Complete System
'�sThe undersigned hereby certify that the Sewage Dis osa S sf6m;Constructed Re aired. raded Abandoned
., g Y fY g P Y � ),, P ( Pg ( ),Abandoned( )
at 2- 02Ct-2.6
has been installed in accordance w't e ons of 3 V15�f (Title 5) and the approved design pla / -built
plans re at o applicat'�n No. 'r ted Approved Design Flow (gpd)
Installer -xJ.
Designer /!1/i ) Insp for Date
The issuance of this certificate shall not be construed as a guarantee that t e system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. �� � THE COMMONWEALTH OF MASSACHUSETTS FEE �^
'?41W BOARD OF HEALTH `
DISPOSAL SYSTEM CONST CTION PERMIT,,--
Permission
is hereby ranted to Construct ) Repair ( Up-rude ) Inct ( an individual sewagedisposal system at / ads:de c'ribed !
in the application for Disposal System Construction Lmit No. dated
Provided: Constr cti ssh 1 be completed within three years of the date of this per ' . 11, cal 'ditions x be met.
Date // 1 Board of Health U f 7S
FORM 2 - DS P DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN rM PUBLISHERS- BOSTON
rom: 12/20/2017 11:49 0239 P.001/001
Town of Barnstable
ofTowti Regulatory Services
Richard V. Scali, Interim Director
'"MNAMM"B`Z Public Health Division
1639.
h
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: Sewage Permit# Assessor's Map\Parcel
_%
Designer: � tlO 6 okod Installer. RL
1
�iAkjT '
Address: � Address:
l�^ti A k
On �� was issued a permit to install a
(date) �+ (installer) I��
septic system at 2 Cv �`"� " l�""� ' based on a design drawn by
(ad ess)
dated
(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. Strap out (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 107 lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactl
VIcerti hat'th system referenced above was constru tom-_, nliance with the terms
appr val letters (if applicable) 4Qf��Fs NDAVIDrVIASON run'
( s er' S azure) ;� No. 1066 0 �:I.
GIs f ETA
011 NI TAMP',-,
(Designe s Signature (Affix Destgnbr s Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUELT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certi$cagon Form Rev 8-14-13.doc
TOWN OF BARNSTABLE
�./ o �
LOCATION "/ � d c��; )(E� SEWAGE# l7 p 7
VILLAGIOX, me-tk/ ASSESSOR'S MAP&PARCELZZ-jam-
INSTALLER'S NAME&PHONE NW5. 0
SEPTIC TANK CAPACITY /1008
LEACHING FACILITY: (type) -,&, 141 L'4,n Po vJsize)4f<),e/3
NO.OF BEDROOMS
OWNER /t e—//
PERMIT DATE: I��6��or 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
Z5'.�
io
Town of Barnstable Pitrri
Department of Regulatory Services ,
's Public Health Division Date
tb�q �P 200 Main Street,Hyannis MA 026011 4,d
Date Scheduled Time Fee Pd. 1co t
Soil Suitability Assessment for Sewage Disposal
Performed By: 1 ! qAi2_0 Witnessed By:
LOCATION & GENERAL INFORMATION_
Location Address42;(Atfl } 90V�P COAT. Owner's Name���'6��
�a J�"111 'VI Address
Assessor's Map/Parcel: Engineer's Name ic)i"%A
NEW CONSTRUCTION REPAIR Telephone# 6� 10'
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
Parent material(geologic) Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
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 Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time
Observation
Hole# Time at 9"
Depth of Perc l Time at 6"
Start Pre-soak Time @ / Time(9"-6")
End Pre-soak .�
Rate Min./Inch '
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.
�,
t� y
a +
A
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,° Gravel
IzA4ii
DEEP OBSERVATION HOLE LOG Hole#
Def:b from Soil Horizon Soil Texture Soil Color Soil Other
Sdfjce(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel
r
I
__ DEEP OBSERVATION HOLE LOG Hole#
Depth from _ Soil Horizon Soil Texture Soil Color Soil Other r
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Graven
it
DEEP OBSERV_ATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Graven
Flood Insurance Rate May:
Above 500 year flood boundary No_ Yes
1
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 pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth ofInrally occurring pe 'ous material?CertificationIntal
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Enviro Protection d that the above analysis was performed by me consistent with
the req 'ning,expe x eri tcedescribed in 310 CMR 15.01 .
Signature .y Date 0J
No........61-113 Fizz GQ•L
THE COMMONWEALTH OF MASSACHUSETTS
BOARD /QF HEA��LT
..... ......OF..... --- ---- ....................
Appliration for Ropoiial Works Tonotrurtion Famit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
-- ..............
............. ......... ... .......
...... ---------- .....
L2lon,Add.�e t 0
. ............... /.#?. j............
............. -------7.. . ........... .......� ;V
3 t.. ..rl, _5
Owner Addr9A.
.................................................................................................. ..................................................................................................
Installer Address
Type of Building Size Lot.Z:?— &b'K Sq. feet
Dwelling—No. of Bedrooms___...--.... ---------_--------_-----Expansion Attic Garbage Grinder WC)
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Other fires
-------------------------------------------------------------------------------------*-------------------- ------------------------------
W Desi Flow..............�,75... .......gallons per person er da . Total daily flow------- -------_-_--------gallons.
Septic Tank—Liquid capacity(Meegallons Length_e4�rFWidth................ 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
..e.Percolation Test Results Performed by 60, 'I`". .__. .. .. Date__
Test Pit No. I....4'Z.- .minutes per inch Depth of Test Pit-__-_ Depth to groundater..��&;�.�
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit...__.......__._._.. Depth to ground water-_-.-.____--------______
I --------
04 ......... -----------r7...... ...i� - -------------------"-------------------*........*------*------------
..... .. ...
0 Description of Soil. V...... ........ ... ........ ......Z......................................................................................
UW ..................................... .........0 ..... ..............................................................
7, --- ---
---------------------------------------------------12�------------- ... .......... ..................15Q09------- ...............................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individtij Sewage Disposal System in accordance with
The
and
the provisions of TITLE HE 5 of the State Sanitary Code—T further agrees not to place the system in
operation until a Certificate of Compliance has brejoged b the o health.
.. . ....... .
" Date
Signed_. .... ... .......... / /,
_17 � t
- Z(iApplication Ap y.......... .........<1:..................................................... .... .....
Date
Application Disapproved for the following reasons:...............................................................................................................
.............................................................................................................................------------------....................................Date....................
Permit No.._..Ss..—Ta2.r..................................... Issued_----- ..................
Date
-----------------—------------—------------- ---------------
No................-....... Fps.....: . '.: .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
+.__r<?4/k ..............OF.....t�Ad L.. ..:_ .................
App iratinn for Disposal Worka Toustrnrtiun ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System aft: J
............/ �:f -�.------ - ...... ra
Loc tion-Address orfLot o.
i Owner Addross
W
,a ...........................•---....----•----•--nst ler........................-------•--•-..... _...........••----------•---------•--•----......dress•----- -----......_..........---------
Installer Address
UType of Building Size Lot...�,..................` Sq. feet
t.a Dwelling—No. of Bedrooms............. ..........................Expansion Attic ( ) Garbage Grinder (mac:)
a`q Other—T e of Building .._...... No. of persons............................ Showers
YP g -•----------------- P ( ) — Cafeteria ( )
Other fixtures --------------.......
-
Design Flow.............. gallons per person per day. Total daily flow------.
W _7 .__ � gallons.
WSeptic Tank—Liquid capacity.----"��.gallons Length_ '_,7-Ar/Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.. leaching area..................sq. ft.
z Other Distribution box (...) Dosing tank, ) f
Percolation Test Results Performed by............. . ..`..... . Date__ /ater
.........__._._.......__..
Test Pit No. 1... ..*,?-___minutes per inch Depth of Test Pit....,f........... Depth to ground , ... f��!` '
LEI Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ............. .......• ---...-------••--......---••--•-------.....................................................
D Description of Soil.....Z) -------•- �.7--- 1 --�--
. -
17
--• -
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
...................................... --------•------•-------------------------------------.......-----•-------------------------------------------•--------------------------------------•--------•---
Agreement:
The undersigned agrees to install the aforedescribed Individu Sewage Disposal System in accordance with
the provisions of TITLi� 5 of the State Sanitary Code—The and si ned further agrees not to place the system in
operation until a Certificate of Compliance has be, Iked b the o health.
Signed--- • _-z ..... .............
Da
Application Approved BY ?l
••---.. _ :
Date
Application Disapproved for the following reasons------------------------•-•-••----------•----•----------------------------------------------••-•••---..........--
...................................................... ------............-----•-•--._....------------•---...............................................................................................
Da
Permit No..... ?' .---
-----•-•--------------- Issued.---.._...,4�------ ..�...._
c1 ..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/. .............oF... %'�.' ...................
C�rr�i�ir�#r of �nnt��i�nr�e
THIS I TO EE TIFY, That Ue Individual..Sewage Disposal System constructed•( "or Repaired ( )
==
Ins all r ,,,•-�r
at.............. -- �-••-•-....__ �.f'_". �`� ------------ --- ..........................................--------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated-------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE �.. Inspector... ---------- --_-_--------------••------.---
THE COMMONWEALTH OF MASS CHUSETTS
BOARD F HEALTH
C ...ro. ..........OF........ ..................................................
f -.~ FEE.
rkii Tonstrnrtilan amit
,,-
Permission is hereby granted- f(.....•- ------ V......... '
to Construct (--1"or Repair ( ) an Indd*i,'dual Sew a Disposal s
atNo.- 11= € .-_.V� ,l -•-------------------•-------------------•----............
Street
as shown on the application for Disposal Works Construction Permit No :..':__.._.`s-'_ Dated..........................................
........................................................................................................_
Board of Health
DATE....•............................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
LO A ION �a SEWAGE PERMIT NO.
�O�
VILLAGE `
I N S T A LLER'S NA E i� ADDRESS
f -� c" k V
B U I L D E R 0R OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
I
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r IAJGU-_ FAMILY - 3 gCOROOM 3rticr '
'
P t s f.
u o GARBAGE G
pAtL�( FLoW a 110 Y. 3 Z3oG.Pfl sulk; LIAM CL'.
JEPTIG TASK = 330x15o'/. A976.P. O
tJS� 1000 6A►1.. .off �� of v Nj E. y g
jQ
1 v 00 GAL. ��J���c Jr' . 4 Q�sTt �y�-
plSppsAL PIT usE
i �� SUKy
S�DGh/pL� AQ.L-A• • 150 5•� - �
ego S.c, � ,'t•5 � 3�5 G.pR
80TtOM AREA t . f o ciF•.
Y SA c�51�N = .4.25 G.00- 5 `
e r^%. pA 16Y F�.Ow! 33o G.Po r
t iPEsQCoL.A?ION RATS t 1",W ZMIN OV.LE55
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rir_ •vemCnTC`J t7E'TER.'^��� oT L !NP-'5 /LDP<✓IGA
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PE2GoLATION RATE : 1"IM ZMnI
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ASSESSORS MAP: p,_�_
,�✓ TEST HOLELOGS
�U PARCEL: �2
1) The installation shall compl with Title V auJ '['own of oard o I
FLOOD ZONE: P L SOIL EVALUATOR: ► 1 �(�4`✓"�OIr--� �n..� � f
�J� ! �'✓ . .._ _... Ilealth Regulations.
WITNESS : ', 1 �.111� ULlV1(LI
REFERENCE: %� 2) The installer shall verify the location of utilities, sewer inverts and septic
DATES
�� _ components prior to installation n i
P P and setting base elevations. i
PERCOLATION RATE: .-' 1 T ,
► 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 per foot. The First
two feet out of the d-box to the leaching 1 _ � �1 ✓ shall be level
TN- I 4) This plan is not to be utilized for property line determination nor an other
TH-2 P P Y Y i
purpose other than the proposed system installation. :
5 All septic components must meet T
� i ) P p Title V specifications.
(� 2, 1 6) Parking shall not be constructed over H 10 septic components.
"l r �b ,1 ► 7) The property is bounded by property corners and property lines.
p P
LOCATION 8) The property owner shall review design considerations to approve of total
AT I ON MAPv'D,
r design flow and number of bedrooms to be considered for design. Receipt
of payment for the plan and installation based on the plan shall be deemed
C v approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material ,
per Title V abandonment procedures. Those within the proposed SAS shall
P p
be removed alongwith contaminated soil and replaced with c 'p lean sand per
Title V specs. i
o ►rIQ n 2Wv 10)System components to be 10 feet from water line. Sewer lines crossingthe 1 '!
water line shall be sleeved with 4 inch SC1140 PVC with ends grouted it
�- applicable. .The proposed SAS is being installed below the water service
line. The line is to be sleeved as aforementioned and maintained in place.
SEPTIC SYSTEM DESIGN
11) 1f a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
FLOW ES'T I MATE 12)The installer is to take caution in excavation around the gas line it such ,
exists.
r� BEDROOMS AT I I� GAL/DAY/BEDROOM - ?j 0GAL/DAY 13)Tile installer shall verify the location, quantity and elevation of the sewer
a lines exiting the dwelling prior to the installation.
i
SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting �
Title V requirements.
�' GAL/DAY x 2 DAYS GAL
USE �t7C�GALLON SEPT I C TANKI
I'
aKt�l..tOliJ
S01 L AIISORP; 10 SYSTE
. ;
,/ - - �^'� e if--li;✓ �+� � �i �-- ��0FIt�
i
f o� DAvla z
SIDE AREA; ; , X ZCJ ,.f ` XzX � _ ( � ��97
BOTTOM 0 c
TT M AREA:
C�►� - Z?j � . MASON m
O O v p�Na 1066�0 o-y
— s
SEPTIC SYSTEM SECTION
u ;
0►,
-�� l-1� u i U•l(0 1
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