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2250 FALMOUTH ROAD/RTE 28 - Health
2250 FALMOUTH-ROAD, CENTS .VILLL- A=168-135 SUI 14 0ea llll UPC 12543 �a No 5`3L. OR g�stco °o HASTINGS, MN TOWN OF BARNSTABLE LOCATION (� Z 'M Qu �� SEWAGE # VILLAGE � V\. ASSESSOR'S MAP & LOT, F l36 INSTALLER'S NAME&PHONE NO. '\C C1 SEPTIC TANK CAPACITY SZ d �rct L Q 30>C LEACHING FACILITY: (type), 1 1 (size) NO.OF BEDROOMS 6 BUILDER OR OWNER S CAJZ1\Z-%.- CC0^5-S l'a-C PERMIT DATE: �. ' / _COMPLIANCE DATE:'2�I 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 fe7 of leaching facility) Feet Furnished by � � a 9t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for 30i_4paal *pttem Conmruction Permit Application for a Permit to Construct( )Repair( 1/)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. �� YC,(rAOU'tn n_ O er's Name,Address and Tel.No. Assessor's Map/Parcel 3�5 Installer's Name,Addressand Tel.No. Designer's Name,Address and Tel.No. CCU I" V c-=,.._/C_ Type of Building: Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinde4o Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) nS 2 MG..SC 'kt`C O c5*—Z, 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 Envi Code and not to place the system in operation until a Certifi- cate of Compliance has been issqj by this oard of ea Signed Datey� Application Approved by Date !2 6 4 Application Disapproved for the ollowi' g reasons Permit No. Date Issued No. tr y Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z[pp ication for Mi5po5ar *pgtem Construction Permit c Application for a Permit to Construct( )Repair( Vj Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. C pQ J v O er's Name,Address and Tel.No. Assessor's Map/Parcel /' , �� vx-,1 1"U n Installer's Name,Addressand Tel.No. Designer's Name,Address and Tel.No. ,C C.CU� h'-, rt�l/� C(�C�k 2 V Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinde4o Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) r`S C) C)uvx 2 M L.i �e'E o Date last inspected: _b 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 Env' al Code and not to place the system in operation until a Certifi- cate of Compliance has been iss4 e by this oard of ea Signed Date Q/3G 9 Y Application Approved by Date !t2 36 ��$ Application Disapproved for thkollowin'g reasons Permit No. Ll Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( 4pgraded( ) Abandoned( )by -S C, C5 n S e, at a2 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. q8- X?6/ dated Installer Q<c, �A M �`- r-o.J�L! Designer The issuance of this ermit shall not-be construed as a guarantee that the system 11-f. ction as designed. l Date r,2 / ' Inspector —————————=————————————————————————————— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpo.5ar *pgtem Construction Permit Permission is hereby grante to Construct( )Repair( VUpgrade( Abandon( ) System located at 10_ y)S_() ne- CX-L4-c "k (�=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:Construction must be completed within three years of the date of this pent Date: - 9 Approved by 7/98 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, �� e� ,�, , hereby certify that the application for disposal works construction permit signed by me dated L,2() l l ) , concerning the property located at �-� (v-,UOtk Rd meets all of the following criteria: (There are no wetlands located within 100 feet of the proposed soil absorption system. There are no private wells located within 150 feet of the proposed septic system. •/'There is no increase in flow and/or change in use proposed. •/�!here are no variances requested or needed. •/ If there are any wetlands located within 250 feet of the proposed soil absorption system,the (observed groundwater table is 14 feet or greater below the bottom of the leaching facility. /• I understand that the attached Title V Calculation Chart may only be used for the design of a septic system if the existing naturally occurring soil is classified as Class I(sand or loamy sand) in the most hydraulically restrictive layer included within the five foot zone beneath the proposed soil absorption system. If the soil conditions are not Class I within this above described zone,a professional engineer or registered n is aired. SIGNED : DATE: 36/'d LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER Please complete the following: A)Elevation at top of ground in the location of the proposed soil absorption system ' 20 B)Elevation of groundwater [Attach a sketch plan of the proposed system. Also if the licensed installer possesses a certified plot plan,this plan should be submitted]. q:health folder:Cert2 l I� a _ 1� � 9' f j�e. 1 Y Q D TOWN OF BARNSTABLE LOCATION L nit 0 QfIA �� SEWAGE # VILLAGE C�Q k ASSESSOR'S MAP & LOT AO'^ Q INSTALLER'S NAME&PHONE NO. S//6 `I' C-3- SEPTIC TANK CAPACITY /SZ® CB"'��- Q('32X LEACHING FACILITY: (type) C'Xl r-'--6 rat f` (size)2/1,,P� S� NO.OF BEDROOMS BUILDER OR OWNER �S PERMTTDATE: / _COMPLIANCE DATE:_ / A IE f � 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Lt within 300 feed of leaching facility) Feet Furnished by J is • -� A-Au (�I T � / I f 4 r s I t�c� —o el —oo No.............._...�'�� .tr ..................._..... x THE COMMONWEALTH OF MASSACHUSETTS T' t -BOARD F H LT I-� ��----------------- F... .... . ..... . ..... ............................. Appliratiuu for Diipuiittl Workii Tonstrur#iun Pprutit -- Application is hereby made for a Permit to Construct ( t�r Repair ( ) an Individual Sewage Disposal Sysyem1t N .... .. - - .... . .... ... ---L ion-Addr or Lot N . � ......----- .__ _.... .. . . .� ... , ner Address W ..........................•-•••--••....._...-• ... .--------- ......:.......... .....-------^ Installer Address Type of Building 7 Size Lot.,-:_f17t��.. ------Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) U '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ................................... W Design Flow.............. ,.._...._..........__gallons per person per day. Total daily flow.............s_�l?_.............._allons.. it WSeptic Tank—Liquid capacity/OAQ-.gallons Length__ --O•.. Width__.4. - O. Diameter________________ Depth......... x Disposal Trench—N o. .................... Width.................... Total Length........j...___'�... Total leaching area..................... ft. Seepage Pit No--------------------- Diameter.Q._-.,3._..... Depth below inlet._�Z..��__..... Total leaching area.��.....sq. ft. Z Other Distribution box (�� Dosing tank ( ) � q� '-' Percolation Test Results Performed by._ _ . . t4!ICI a .. / Test Pit No. l..ar --------minutes per inch Depth of Test P __1 epth to grd water. �, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to grind water........................ Description of Soil �a f� .. ..................... ------------------------------------------------•------------------------------•---•--------...._..---------------------------------------------•-------------------•-------••--•-••-----------•••-•---- 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 iITLi: 5 of the State Sanitary Code—.The and sig d ther agrees n place the system in operation until a Certi of fiance has been issued by the b 1 h. i�.�1 dJ:. ���,. a�..`�. ..d . . . ........BZ� /yt(Li 4 �ev Q EM Da Application Approved By.....•--••-•-- Da e Application Disapproved for the f o o ing reasons:-----•.................................................•-----------------------------------------............._ --------------•------•--••---•--•--...........--•----•-•------------.....--•----------------•------....--'•----•---------------------------•-----...••--••--------------••--------... •••••.....••. Date PermitNo.......................................................- Issued_....................................................... Date ..r No............ •--•-_.. Fics................_...._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................-•-----.----.....OF............................................... Appliration for Dispooal Works Tonstrurlion Frrmil Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....:...........__.............................................................................. _.....-------------•----------...--------------•-.._..----..........--------......-_-.........._.. Location-Address or Lot No. .........--•----•••------..................................•......----------•--•-_..._...._._.... . ......................................................__.....----.......................--.....--- Owner Address W _ Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of ersons____________________________ Showers QI YP g --------•----------••------- P ( ) Cafeteria ( ) a, Other fixtures -------------------------------------•-••_..... W. Design Flow........................:...................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No--_---------------- Diameter........-__---___-_- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~" Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ Lt, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •................................................•••-••--........-•---------•-•-•---.._......_------..... •••------------- ••-•-------------------------------- 0 Description of Soil..----•--...------•-----•.......................................................................................................................••••-......--•-------_.. W 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 iITL . of the State Sanitary Code—The unde ig d ftrr�ther agrees n place the system in operation until a Certi ca of Compliance has been issued by the b r o heal Signed...................................... •- - .. ....--- -- _--- � J.,Da't Application Approved By................ 6nciQ4.......t ..ram t _ .._.. .__. Da Application Disapproved for the folio- •ng reasons____________________________________________________________________________•--------...-...-....-----.---.___ --------------•...•---•-------•-•---•--...._.._....-----•----•----..........----•------•--............._..-•-•-•-•-•--•--------•---•----•--•--•-•------•------••-•---••--.....••----••--....--•------.... Date PermitNo..................................................._...: Issued............................................--.......... Date THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH ................. ..............OF.............�� .5..............................._... fIrrlifirate of Toutpluturr THIS IS TO CE�, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ••. Installer at .. . .............. e= g 1 [ .. ... ` --------------------------------------------------- has been installed in accordance with the provisions of TIT kg.-,,, of The State Sanitary Code as Oes ribed in the application for Disposal Works Construction Permit No....... _- ......�.Cl...... dated----------?_/_19 .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIONSATISFACTORY. DATE.......................1.'2 ..� .. ............................. Inspector--•-- ?f✓1 ....................................................... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No� ... ............OF............................... -' F>e�.. ...---... Disposal Works Ton" ltrlion Permission is hereby granted------------------•---•:r.�.��....-_... fmil .......... ..._.............................._--__ to'Construct ( �C) or Repair ( ) an Individual w.geA^D�isposaa.System < atNo..•--••••-•-•-•-----•------ - d... - �! - r..._•----• _ 4............. Street ,�. as shown on the application for Disposal Works Construction Permit No............ .. .. Dated..__._._._.: .:.._.�.................... ------------------------------------ DATE.----- --- _ S ------�-'.................................. Voi f e tti FORM 1255 A. M. SULKIN`, C.. BOSTON TOWN OF BARNSTABLE LO-CATION L.&+ 5,- 4��G.2� SEWAGE VILLAGE_(_P, y ASSESSOR'S MAP Cz LOT INSTALLER'S NAME & PHONE NO. ` � 5 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) p!-r�- (size) /f1l1 0 NO. 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