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HomeMy WebLinkAbout0115 KNOTTY PINE LANE - Health 115 Knotty Pine Lane Centerville A = 191 — 080 , I No. ;to/3 6o Y l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for Vsposal 6pstem Construction VPrmit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No Owner's Name,Address,and Tel.No. Gets✓ `%ol��'',p�6*�,r�j Assessor's Map/Parcel —00 Installer's Name,Address,and lfel.No. l Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms In, Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ®'�.� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided 3 gpd 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) 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 Certificate of Compliance has been issued by this Board Ith. Signed Date Application Approved by Date Application Disapproved by Date 1 for the following reasons Permit No. 2 o f 7 6 d Date Issued 9" o G O z_. S i. No. - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC-HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Misposal &pstem Construction 3permit Application for a Permit to Construct Repair(` lluPgrade Abandon ❑Complete System �ndividual Components e Location Address or.L'ot N%5�yyp�y /0101_4Gr Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Po a" Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �7f' O 707 Type of Building: L s Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ©e f-.P . No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) O gpd Design flow provided 3 gpd Plan Date �"� S` —/ Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 1 Nature of Repairs or Alterations(Answer when applicable) F 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 Certificate of Compliance has been issued by this Board o Ith. ` Signed \ Date Application Approved by Date �'f — — /2" Application Disapproved by Date for the following reasons Permit No. W 3 ` 36 d Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(M/o, Upgraded( ) Abandoned( )by C'/� �G��S p�`!/�"_ �'��T/ G _P !/c- at_�/S` /�o7J�Y P�J✓�" �'• has been constructed in accordance with the provisions of Title 5 and for Disposal System Construction Permit No._')_o j 3 —3 0ated Installer Designer #bedrooms Approved de i flow S/ gpd The issuance of this permit hal of be co trued as a guarantee that the system it n tion as design O Date Inspector �- ( / No. 010/3 "" 3 0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair(A� Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. ` Provided:Construct/ion must be completed within three years of the date of this permit.,.. Date — / /2, Approved by C fd S 4 rl SEP/20/2013/FRI 08:23 AM FAX No, P, 001 "down of Barnstable Regulatory Services Thomas F.Geiler,Director RA XAM M ' Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: Sewage Permit# ` Assessor's Map/Parcel ,9/_ o ODd Installer&Designer Certification Form Designer: ��, � Installer; 4 WF .6fpRc Address: �J t ^I�GI.�C "f Address; On ��`� -� was issued a permit to install a (date) (Installer) septic system at based on a design drawn by (ad ess) ,Q�7 dated \ (designer) 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. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with nsajor changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local P- '-bons, Plan revision or certified as-built by designer to follow. Stripout(if rP acted and the soils were found satisfactory, �J��k�pFM4' DAVt' B « (Installer's Signature) MASON m' ,sr / er s Signature) _ PLEASE RETURN TO BARNSTABLE PUBL.- OF COMPLIANCE WILL NOT BE ISSUED ITN.i y, qv i n i tiilj t,'UR.M AND AS- BU LT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU. gaoffice FonnsAesignameditication fonn.doc TOWN OF BARNS/TABLE LOCATION L�EWAGE# VILLAGE ASSESSOR'S MAP.&PARCEL 1 S91 — 00 O INSTALLER'S NAME&PHONE NO. �/-W Z e�'49 4f_d"0f- 7.7 = ® ��7 SEPTIC TANK CAPACITY 67 /0 e 0 ai4 2, LEACHING FACILITY:(type) .W4!% size) NO.OF BEDROOMS 3 OWNER PERMITDATE: �` ei��°-� COMPLIANCEDATE: Separation Distance Between the: Jz� 1-�✓J�7�� �/ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /0) 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 �Z:4X Q I � S A - a3 Air 0 as• oo ,w - J O. V ,/- .0 elT Ilf eea Town of Barnstable P# ' 4/- Department of Regulatory Services F Public Health ' >�. D1VI$]lon Date q 113 200 Main Street,Hyannis MA 02601 t Date Scheduled 'J (� /j -/ .r^ Time Fee Pd. Soil Suitability= Apessment for Sew Performed By: Witnessed By: B LOCATION& GENERAL INFORMATION Location Address �/ Owner's Name CC��r Address��/YJ� Assessor's Map/Parcel: / JQ Engineer's Nameel-'2-A!/� /� NEW CONSTRUCTION REPAIR Telephone# L �Cl'Y.� Land Use Slopes(96) ` Surface Stones Distances from Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property lane ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) J I, G 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 soll 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 Observation PERCOLATION TEST Bate., 'rime___.__ .� I Hole# "5. Time at 4" LJ Depth of P= c3o Ttme at 6" i Pre-soak Time @ At ti.. Time(9"-6") End Pre-soak t3. � wRae MinJlnch Si et`�Suitability A�'�S osment: Site Passed Site Failed: Additional Testing Needed(YIN) Ori.a]: 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 Conseirvation Division at least one(1) week prior to beginning. Q:LSEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. / ConsistencLravel / l � -d5 Cl) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% v 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 Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cons' en Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Within 100 year flood boundary No— Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u�s majerial exist in all areas observed throughout the area proposed for the soil absorption system?If not,what is the depth of naturally occurring pervious material? 16A Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was perfo ed by me consistent with the required training,expertise a xpe " e des bed in 310 CMR 15.017. Signat a::�) Date Q:\SBFMMERCFORM.DOC � a , �- ��� i i 1 -------------- o 9., r. 4t7- ASSESSORS i.IAP : 1 o Sl - 0 L-. LDS" FLOOD ZoIIL• : i C. SOIL EVALUATOII: t AV1 1) I'Le rnslallalion shall coon,►, with "Lille V and 'Town of Mild of � U`� u.-.,_..'.L..� ._ ,. �?!� :�,..��.......-�.... I leallh 1Z rations. r ego • _ IZErEHINCE . � �. '�-t ��� � _ DATE. 2 I'he :nstfiller shall vei ii'y the location of utilities sewer inverts and septic components prior to installation and setlin T base eleva(ions. rErscoLAT I orb 11A�rc. ..�. 2.� ,. � � I I � � l ug h, 3 All gravity septic piping J to be t inch Sch Ill I V( at 1/8 per lbot. 1 lie first 11 � ....�. � b Y i 1 1 6 , , two leet out of(lie d-box to the leaching shall be level. TIJ�2 4 t - 4) 'I'his plan is not to be utilized lipr•properly line determination nor any u(lier _.____ purpose other than the proposed syslem h)slallaliou. 5) All septic components must meet'l'itle'V specilications. 10 �,��, `J G) Parking shall not be constructed over 1110 septic eoniporienls. ,' l "3✓� 1 ILI 7) The property is bounded by properly corners acid property lines. �jU 8) 't'lie property owner shall review design considerations to approve ol'fatal LOCA 101� iv ' s l design flow and number of bedrooms to be considered lur design. Receifpt 1 of payment for the plan and installation based on the plan shall be deemed approval of file design flow by (lie owner. 9) 'I'lie existing leaching or cesspools shall be pumped and filled with material per'Fille V abandonment procedures. Those wilbin the proposed SAS shall I be removed along with contaminated soil and replaced with clean sand per 1� p � (/-fp �I Title V specs. 10)System components to be 10 feet hom water line. Sewer lines clossiug-.(he water line shall be sleeved with 4 iricli SC1I 40 PVC with ends grouted i,f applicable. The proposed SAS is being installed below the water service - line. 7'he line is to be sleeved as almementioned and maintained in place. t SL- P1 I C SYSTEM DES I Gil 1 11) If a garbage grinder exists it is to be removed and is (lie responsibility of the owner to ensure such. 1 V FLOW EST I MATE i 12)7'he installer is to take caution in exerivation •u >otind (lie gas line if such I I ti exists. BEDROOMS AT GAL/DAY/9EUi1001A -,Z GAL/DAY �3 Fhe installer shall verif the location (111,11 ti( I ' � _-- -----•-�---------�ay- �, , ._-._ ) Yh , ey and el eva l i oil of(lie se�-tie(. 15c>. ` / ; lines exiting file dwelling f'irior to the ii►slallatioii. SEPTIC TANK 14 'FIns plan is re nesentative onl lh; •i t 1 I y it . systcui can lit on a property nieetii,ig s I Title V rec uilements. GAL/DAY x 2 DAYS - � GAL USE t000 GALLON SEPTIC TANK �� t � ... t = _ I L AE3Saf1PT oi� SYSTEM aM s t i Gjk OF DAVID MAS04 co Am �� ' SIDE AREA. �C �.� —I 1 oil AA f J v 116-4t 4 a �, BOTTOM AREA: X I, � � , sIV s : 0! SEPTIC SYSTEW SE I ON I I _. a o � DVAL .-fit_ CO I �� — ,` '�,. �► t lb i�J i�--�� � '" �� to sl 36 �C ► f �a 51avt'c. oR(xmlPat�lY�t7 `li-13�X GAL �► ,� �ilf2"( 51, i? J5 '-- �r' y 91, i Y� BAN C Only _ S I T E AND S I- WAGE P LAH I A►-4K ►i S CA I_ DAV I D B , iAA3011,R5 DA i E- DBC ENV I ROHMENTAL DES I GIJS �l II A I...AJ� � J�3'3� i --�� 177 v1A DATE r IIEAL GIN t 50 5 w ►