HomeMy WebLinkAbout0128 ELIJAH CHILDS LANE - Health 128 Elijah Childs Lane
Centerville
A= 171-247
S M E A D
No.2-153LOR
UPC 12534
sm"d.com - Hach In USA
mammmom
IFI ���
OF rl*Sq
Fee
No. (f
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIppficatiou for Ti5po5al 6p5tem Con.fStruction Permit
Application for a Permit to Construct( ) Repair Zupgrade( ) Abandon( ) ❑.Complete System Individual Components
Location Address or Lot No/029 A/+ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel / r 42,Y)
Installer's Name,Address,and Tel.Ne.,J&;414 e(o.^$T Designer's Name,Address and Tel.No�. :7wYj_6 lmf,GA)
Type of Building:
Dwelling No.of Bedrooms Y Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets /$ Revision Date
Title
Size of.Septic Tank f Type of S.A.S.ON, 5
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)—Zaa®fir W d4/o'�Q�
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 oj the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this oar of Heal
Signed Date ! 4 lu
Application Approved by dy 4Z Date q ;'.a 0
Application Disapproved by.ol' Date
for the following reasons
Permit No.?V 10 �—��q Date Issued
No. t•�� i— ;y._ '' 3 t 1 Fee
x Entered in computer:
_ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
App i ettiou for IDiow6ar *pgtem Con0truction Permit
Application for a Permit to Construct( ) Repair grade( ) Abandon( ) ❑.Complete System V Individual Components
/� fLi.Z¢// C/00-s `N.
Location Address or Lot No. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 171r o2V? 71 M f,, sc"4
I staller's Name,Ad ress,and Tel.No�&)441 6,71- Designer's Name,Address and Tel.NOT,/1j//�
Type of Building:
Dwelling No.of Bedrooms Y Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) (/f/U gpd Design flow provided 4i'yZ gpd
Plan Date ��/7��0/C� Number of sheets Revision Date '
Title
Size of.Septic Tank IdI29 / Type of S.A.S.b?y. ?,/
Description of Soil A16liys, C,1�479
Nature of Repairs or Alterations(Answer when applicable) - ,?(1 ,,,' 65 ,Q& 44 S
pf sib &1,4d /./G egxlpl GS Y
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 Titl4qx,
f the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by thi PBof Health? / /
Signed Date A u/ "
Application Approved by Date I /6, Z ov 0
Application Disapproved bylo Date
for the following reasons
1 Permit No. U ( �i 1 Date Issued j( G1 &/d
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
tt � t
at t 1c,� C N Jd f has been constructed in accordance
`' D (/ _V q
with the provisions of Title 5 and the for Disposal System Construction Permit No. o / G ( dated
Installer ,` Designer
#bedrooms 7 Approved design flow ��U gpd
The issuance of this permits all not be construed as a guarantee that the system will funct'i;on\as d signed.
Date i / �//o Inspector
—_--No--�Ujyl�b�------- =Fee .`l./# =—_----�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
1=igpogal 16;�)pgtem Construction Permit
Permission is hereby granted toConstruct ( ) Repair ( ) Upgrade ( ) Abandon ( )
System located at I' 0 r4//L7,f// ew 40s 1.Q'ru_ �•�7G�F//l�
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: ConsJtructtiiont must be completed within three years of the date of this-permit
Date l°� ! //0 Approved by C - -
Town Of Barnstable
Regulatory Services
*. Thomas F.Geiler,Director
+ IARWSTA$LE,
p " a Public Health Division
Thomas McKean,Director
200 Fain Street,Hyannis,MA 02601
Office:.508-862-4644, Fax: 508-790-6304
Installer &Designer Certification Form
Date: �3i Zd I O
Designer: l 'v���p1i"I Installer:
Address: . �L � i �� Address:On
was issued a permit to install a
(date) (installer)
septic system at 1-ZY iZ L-:%3X4 CAZ t based on a design drawn by
p (address)
dated , r 1? 1714> to
(designer)
V ];'_certify that the septic system referenced above was installed substandall;, accb d�
..�. .ng to
he design, which may include minor approved changes such as latera relocation of the
distribution box and/or septic tank, _
I certify-that the septic system:referenced above was installed tenth"major:changes(j,;e,.
greater than`l U' lateral relocation of the SAS or-any verti cal.re�ocat►on of any component
of the septild4system)but in"accordance with State &Local Regulations. Plan revisoxt or.
certified as bo It by designer,t6 follow.
DAVID. . �y.
stall Signature) [3
` ►S rrGP
4 6 T-AFl1P
(13 er s Signature} (pfix e gner's,Stamp Here) .
PLEASE RETURN TO BARNSTA&LF PUBLIC-HEALTH.IHYkSIOPT. C RTIFIC TE
OF CONL�PlGIANCE WILD, SSU.ED: :BOTH T$lrS,FORKS _
BUILT CAS ARE_RECEI VED Bw7 :B . STALE PUBLIC SALT$DI'VISIE3
THANK YOU
p e/DesignerCertificafionPorrn
Q:Yealtfi/Se �u f
t`,
Town of Barnstable . P# 13/3 9
Department of Regulatory Services
Public He alth Division Date
tb39 o MKSa 200 Main Street Hyannis
P -
MA 02601 }
Date Scheduled 1 7 Time
// d
Soil Suitability Assessment for Sewage.Disposal
Performed By
Witnessed By: - �v,r
Location Address LOCATION& GENERAL INFORMATION
/.g Cl/� � Owner's NameJ�Ak4i4N/
72✓�Yi-/G2_ S /�! Address/.Z8
Assessor's Map/Parcel: i I L1�
Engineer's Name—, gy�•� � 0�,9,S�iJ
NEW CONSTRUCTION REPAIR Telephone#
Land Use Slopes('fo)
-'Surface Stones
Distances from: Open Water Body ft Possible Wet Area
ft Drinking Water Well ft
Drainage Way ft Property Line _R Other
ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
+1
. ' r
4• Y�
C
Nam;
Parent material(geologic) Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERNUNATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in, Depth to soil mottles: ,jn
Depth to weeping from side of obs.hole: in, Groundwater Adjustment In
Index Well# Reading Date: Index Well level. Adj,lhctor-,,,,.m„4- Adj.Groundwater level ,,e
PERCOLATION TES` ' Djae Time
Observation 1
Hole# 1 Time at 9"
Depth of Perc Time at 6"
Start Pre-soak Time @ iz
'lime(9"-6")
End Pre-soakRateMinJlnch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
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.
QASEPTICVERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
i ten(-Myb Gravel)
- Z0 L
71
s
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling
(Structure,Stones,Boulders.
onsisten -% rave
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)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color 5011 Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consi ten I
Flood Insurance Rate Man:
Above 500 year flood boundary No— Yes
Within 500 year boundary No , Yes,,_ :r
Within 100 year flood boundary No.Y Yes
e
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervio aterial exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of n rally occurring pe ious material?
Certification.
I certify that on �O (date)I have passed the soil evaluator examination approved by the
Department of Environ ental Protection and that the above analysis was performed by me consistent with .
the required training,ex
p se d experience described in 310 CMR 15.017.
Signat Date �� �7 ZO� d
Q:\SEPTICIPERCFORM.DOC
TOWN OF BAR//NSTABLE
LOCATION /VL SEWAGE#o?,010 —
'VILLAG�� , / ASSESSOR'S MAP&PARCEL ► I '.�
INSTALLER'S NAME&PHONE NO ��/?�;�/,�l ,/2�f�
SEPTIC TANK CAPACITY/��-, /
LEACHING FACILITY:(type� ��� (size) ��'
NO.OF BEDROOMS
OWNER
PERMIT DATE:f1,11GteBU COMPLIANCE DATE: !9 ®d U
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
I
s
�S3
.Y9 ,
�lU 'IGN �a'�tT.
Fxs..... p...........
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD HEALT
...............oF........ ..................�.....
, ppliration for Disvniia1 Works Tonstrnrtinn rrmi#
Application is hereby made for a Permit to Construct (e--'or Repair ( } an Individual Sewage Disposal
System at:
. ti ca w s-
----------------------------•--...........-----•----•-----------
.-cation-Address or Lot No.
y� Owner Address
Installer Address
dType of Building ( Size Lot.rt.. .._._Sq. feet
U Dwelling—No. of Bedrooms................................. .Expansion Attic ( ) Garbage Grinder (14'®
Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q04 Other fixtures -------------------------------- --- -
----------------------•---.--------..----•----••-•------------------------
W Design Flow........ ....................gallons per person per day. Total daily flow.__..--------._�.�... ..........gallons.
WSeptic Tank—Liquid capacit}.QP _.gallons Length................ Width................. Diameter_______-.______- Depth................
x Disposal Trench—No..................... Width.............__._.._`Total Length.....................Total leaching area____-_------_____---sq. ft.
Seepage Pit No........�____--. Diameter f . below inlet.................... Total leaching area....._............sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
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........................
P�
0 Description of Soil.....................................................................................--------------....----------------------------------------------------------------
x
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 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 iss ed by the ar of health.
Sined-- -- ----------------- -- •--- ---------------
/ Date
Application Approved BY = I/...............................
Date
.Application Disapproved for the following reasons:----•---------•--•--------------------------------------------------------------•----....----------------...__..
..-•..............................•------.........---------•--•--•--------------.......------....------..._.....-•--•---••------•----------------------------------------------------------•------------
Date
PermitNo....................................................... Issued-.....................................................
-
Date
w
.................. Fizz...........
i...`: ......._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD (?�F HEALTH
AppfirFation for Disposal Works Tonstrur#ion Vvrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Locations Addd ss / ���� r� / or Lot No.
..' /--- J_.:[�__ Z. .......! f!:::.�z. ........................... ....5. _G—.E_i�'_f.. VZZIZ:4E F.......................................
Address
w .. a ' ........................................ ......./� ------------------------------------------------------
Installer Address
11 Type of Building Size ....Sq. feet
Dwelling—No. of Bedrooms................L�-.L-•---•-._-._-__--_---Expansion Attic ( ) Garbage Grinder (41
'4 Other—T e of Building ............................ No. of persons-----------------•_.-__--___ Showers — Cafeteria
Otjier fixtures •----••---------•---------------
W Design Flow.._..__._.. ......................gallons per person per day. Total daily flow.............. .._ _............gallons.
9 Septic Tank—Liquid*capacit 4�T ..gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No..................... Widt ...............-. otal Length.................... Total leaching area....................sq. ft.
Seepage Pit No._-___�:....... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..........................................................-----•-----••-• Date........................................
Test Pit No. I................mmutes 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........................
R+ •---•-•----------------------------------------------------•---.....-------------------•••--------••.........................................................
ODescription of Soil........................................................................................................................................................................
x
U -•••-•-•-••--•-•-•-•----•••------•---•---••••-•-•••-•--•••••-•----------------•-•-•............•--••--------•---•-----•......---•-••---•------ ........................................................
w
------------------------------------------------•-----------------------------------------------------------------------------------------------------------------------------..._...........---•----••-
U 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 TITTIE 5 of the State Sanitary Code—The undersigned further agrees not to 0a, the system in
operation until a Certificate of Compliance has been ' s ed by the b - d of health.
'-Siigned` . ---. ....... ... .......•--............------.....---•-••••
�}�,rj� ✓ / Date
ApplicationApproved BY............................................... ...•-•-••••----•----••••••..............••.---•-
Date
Application Disapproved for the following reasons----------------------•----------------------------------------•------------------------•--•----•.........-•-•--.
..............•---•--•-------•--•--------....._......._...._..-•--•-----•-----•----•---•-....•--••-----..._...-••---•--•-----•-•---•---------••---••------•-----•••••-----•---•----•••---•-•••-••-------.
Date
PermitNo......................................................... Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF;) HEAL.T,H
..........................................OF.....................................................................................
urdif iratr of TompliFaurr
THIS IS--T-Q CERT FY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by = ......................................
r . mac.it's ins.aii ............ ;-Ij.�`ai° �---•---•----•-•-•---------------------------•---•---•-•-------
at....---•---••-----------•-G---....----•---- .....-•------------------•••-••---•-----•-----•-----•-•--••-------•-••-•-•-•-----•••...................................................
has been installed in accordance with the provisions of TIC' `Y, 53)fg e 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..................61112:2,� Inspector -� �/a-- '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD `OF, tfEA L�
��GL d
//�'i L �3 ...................................I......oF...............................------....---•.....--------•..-....•--..........--.... j
No....L�..:.�......... FEE........................
Disposal Works Taon#r ion rrmit
Permission is hereby granted...............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street i
as shown on the application for Disposal Works Construction er Noy_--._... ��_�t�d;r�----------------------------•--_------
.....
Board of Health
DATE............................................................................... /
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS J�
UJ A T ION r SEWAGE PERMIT NO.
VILLAGE
VLLLq
INSTA LER'S NAME i A DRESS
�Qear 9- oV e Gm I etc,
Into. �4A,.w t CAA. LAA,5 S .
B U I L D E R OR OWN ER
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C,.t reV_V 1 u.Q, pv Ar,5- 5 .
. DATE- PERMIT ISSUED V26Jgl
DATE COMPLIANCE ISSUED
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0� ASSESSORS MAP :
-- ----- - TEST HOLE LOGS NOTES:
5 PARCEL: 2,q 7
FLOOD ZONE: _ /Vd7- SOIL EVALUATOR :
WITNESS : 1) The installation shall comply with Title V and Town of Barnstable Board of
' REFERENCE: � U�G2�l� � z�0 BATE: Y`OJT Imo` t n Health Regulations.
__ --
PERCOLAT ION RATE: . G., Z KAI , t U„ 2) The installer shall verify the location of utilities, sewer inverts and septic
components prior to installation and setting base elevations.
,�
'�� ��.... ���� ���� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first
TH- I TH-2
two feet out of the d-box to the leaching shall be level.
A ►� Lo+�M n �{�t v 4) This plan is not to be utilized for property line determination nor any other
q, la 0-3/1 .,t— lti purpose other than the proposed system installation.
I Lt -ju3„1 10
1 5) All septic components must meet Title V specifications.
�� 6) Parking shall not be constructed over H10 septic components.
LOCAT I ON MAP�h�y� 2
7) The property is bounded by property corners and property lines.
8) The property owner shall review design considerations to approve of total
design flow and number of bedrooms to be considered for design. Receipt
lo' -� of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
, �p� �t do
� JO,��,,pp per Title V abandonment procedures. Those within the proposed SAS shall
A '�v `rt'""� '� be removed along with contaminated soil and replaced with clean sand per
1
Title V specs.
10)System components to be 10 feet from water line. Sewer lines crossing the
�' water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
___.____ .-._�____�,.-- --__-__ __ SEPT I C SYSTEM DES I G N applicable. .3he�r-®posed=SAS�beirtg�rm -11
. e is to lwvefts-aforement mamtame m p ace.
IMdb \ FLOW ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
iBEDROOMS AT 110 GAL/DAY/BEDROOM • % GAL/DAY 12)The installer is to take caution in excavation around the gas line if such
�7 exists.
` �t pN f,9 13)The installer shall verify the location quantity and elevation of the sewer
SEPTIC TANK '
1� I lines exiting the dwelling prior to the installation.
/ 40 COAL/DAY x 2 DAYS - OBOGAL
USE ` OOGALLON SEPTIC TANK I�X1M _
I SOIL ABSORPTION SYSTEM
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