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Home My WebLink About0066 FULLER ROAD - Health 66 FULLER RD.,CENTERVILLE A=188.008 SIII 2J�CEOYC(fp��t NoP22-15_LOR �570N5°�� HASTINGS. MN No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[pprication for 3kgozar 6pgtem Con!5truction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel ! _ ad 19 lP Installer's Name and Tel.No. Designer's Name,Address and Tel.No. s Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) 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 l So o Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) v 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 ' e y thr Bo f Health. Signed Date Application Approved by Date Application Disapproved or the following reaso s Permit No. Date Issued TOWN OF BARRNSS-TABLE LOCATION r► �` � '�� SEWAGE # - f VILLAGE ASSESSOR'S MAP & LOT/oa INSTALLER'S NAME&PHONE NO. -7 3) SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 60 K V ?`�- NO.OF BEDROOMS BUILDER OR OWNER PERIvITTDATE: �'- ,L D— $ S COMPLIANCE DATE: 5- 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by 1 / r Y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE} MASSACHUSETTS 0[pprtcatton for Dtgaal *pgtem (fon.5tructton Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. i 117� AI, � Assessor's Map/Parcel / (ate X Installer's Name,Address,and �Tel. }No. I Designer's Name,Address and Tel.No. 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank !SO o Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /SDa r 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 is e y th Bo of Health. Signed % Date Application Approved by Date Application Disapproved or the following reaso s Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERT that t On-site Sewage Disposal System Constructed( )Repaired (-Alllu**'Pgraded( ) Abandoned( )by at s bmR constructed in accordance with the provisi,ns of Tit and the for isposal System Construction Permit No. dated Installer Designer The issuance of this 6,nnit shall not b construed as a guarantee that the system 1 f ction as designed. Date S ` 02 — `f `� Inspector l No. Fee THE COMMONWEALTH OF MASSACHUSETTS " PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS /0 1=t9;pogal *pg;tem Co.n6trurtton Permit Permission is hereby granted to Construct( )_Repair r ( )Abandon ) System located at to �ti �P -- . and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his er 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 t pe it. pp Date: s-� y'- `� Approved by TOWN OF BARNSTABLE C LOCATION .u . �� SEWAGE # VILLAGE o�,ur ASSESSOR'S MAP & LOT 00 INSTALLER'S NAME&PHONE NO._� o- - 7 7 '-da- (19 SEPTIC"TANK CAPACITY - LEO LEACHING FACILITY: (type) / (size) C O NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: _. --„Z.0- or �' COMPLIANCE DATE: `j 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 z 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 � �Z � � � 1 � � , t'` 9 �� // ��. o —_. /� �,� � �, 1/6/99 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) L Qhereby certify that the application for disposal works construction permit signed by me dated — o? y �� concerning the property located at b (fr meets all of the 1�cc following criteria: • The 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 rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • 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 five feet above the mammum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) / 26- V B) G.W. Elevation /0 +the MAX. High G.W. Adjustment .�,�P = ? G DIFFERENCE BETWEEN A and B d O SIGNED : DATE: _a ®� [Sketch proposed plan of system on back]. q:health folder:cert yv 'A 0 C A T IOX SEWAGE PERMIT NO. 66 VILLAGE I N S T A LLER'S NAME i ADD`RESS B U I L D E R OR OWN ER DATE, PERMIT ISSUED _1��2 DAT E ', COMPLIANCE ISSUED 12 L13 - ,?'/ I e� A? Le A A .v F�$... T.1.. ............. ....0 THE COMMONWEALTH OF MASSACHUSETTS !�t BOAR® OF HEALTH � ...........................................O F.........................................----.------------...I.................---•------- Apptiration for Disposal Workii Tonstrnrtinn umi# Application is hereby made for a Permit to Construct ( ) or Repair (/X an Individual Sewage Disposal System at:r .....�_ .._/` --.:6 --- W..... tea; ....-•------------------------------------------------------------- tion-Ad ess or Lot No. Own r n Address Installer Address dType of Building Size Lot............................Sq. feet U Garbage Grinder ( )Dwellin F , g No. of Bedrooms............................................Expansion Attic ( ) p`�., Other—Type of Building ............................ No. of persons------------.__-__-__----- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------•------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.....--.....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 tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--...........I........ .p4. •-- - ------------- ••-------•---- -- ---•----•--- - ---------------•------•-------------------------•-----------------------•------------------ p. Description of Soil ?..._..... ---------------------------------•-------------------------------------•-•- x V ...-•-•--•-•-•••-•-•-------•-••---------------------------•---••--------------------------------•.........---•----•---•-------•---•-••---•-•-----....................................................... W --- -- -------- -- ------ -- VNature 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 iI'LU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issueVbth�e 4b #rdof ealth.4 S e ---- '� n -•-�� ---r-- V ate Application Approved By............................,..._... --.. .....�.�Q...............-•--•-•------- ........... f Dat Application Disapproved for the following reasons------------------------------------------------------------------------------------------ ---------------------- Date PermitNo......................................................... Issued-....................................................... Date �- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ......... C/J/j,�--------_OF...lC%�lF./Lpol�/`�j�P�l Appliration for Disposal Works Tonstrnrtion Prrmi# Application is hereby made for a Permit to Construct ( ) or Repair *an Individual Sewage Disposal System at: � � Location ess or Lot No. ......... .............................................. a �.1!� �D141_ ...1Oye.r � Address . .._.....- � ------- ---------- ........---...........-----.... Installer Address Type of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ---------------•------------ P ( ) — Cafeteria ( ) dOther fixtures ------------------------------•-----------------------•••----•--•••-•--------------•----------•-••-----••••......-•--•- ........_. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............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 tank ( ) 7 Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x .............. ----------- ------- DDescription of Soil---•••. •---•.....A...... -----------------------------•--------------••-----------------------------•••-••----••••••--- x U •--•-----•-•-•--•--•._...•-•--•-•-•••-•-----•--.._..••••-•-•-•--••••••--••--•••••-•••----------•----•••-••••-•--•-•••-••--••--••-•••----••••---•--••••--•--•••-•••••-••••-••--••.-.----••-•-•••......--- ------------•--------------------------•------------------------------------.....------------------------------. ..•... --- --------`-J-,-�--r --------- U Nature of Repairs or Alterations—Answer when applicable...____., ... ��......_.....��/ °l.-I`-111 ...... --------...•--•-----------•-•---•-••••••••••--•...•••---•--•---••-••-•---••--••-•--•••--•-----_.....•-••-•-••••-•-•-------------•---•-••---•••••------••---•--•--••••-----•••••-••••-•••------......•--- 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 a rees not to place the system in operation until a Certificate of Compliance hVbDeenissued by herd health. DYq�! Application Approved BY ` '- r J =•--•--....... 4 ..----- 1 .._._.. D Application Disapproved for the following reasons--------------------------------------------------------•------------------................................... ....•----------------------------•----------•------•----------•--•--------------•----------•---•---------•••••••••-•••••••-••••••-•-•-••--•............................................................ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS IV, w BOARD OF HEALTH ro. , r�rr�, .........OF...... i1�11/�, f �gPr..................... f9rdif iratr of ToutpliFanrr TWI S T CERTIF , T t the In idual Sewage isposal System constructed ( ) or Repaired (�-- bY-------J �_....../�l , .. .------. .... .................................................••--.._................._ / In t er � at........a..../..:. . ------------------------------------------------------------------------- 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_.-.._____.1_.` �!-��G'................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................... =-j ................ Inspector.................... ............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH /0� ...........OF................wwjz;;".._....._.. ............ ............. ....... ... ... ... . .. .. . No.... ...................... too rl o o �o tnul' [rr Permission is herebyranted..�.,1::..._��A --....4w ...r7 .............................•-•--- ... g .. to Constru /( r pair (�glivid wagODis7s stem at No. Street , / ] as shown on the application for Disposal Works Construction Permit ..._ Dated-------- �r� ........... C /V) -------------•-••-------•----...-----•--------------------------------------•••••••••••--...-----...•-•- Board of Health DATE_.............................................................................. FORM 1?55 A. M SULKIN. INC.. BOSTON (r ,� i