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HomeMy WebLinkAbout0017 NORTH WEST LANE - Health (2) 17 NORTHWEST LANE, CENTERVILLE A=189.047 Iq \7 I E ME6 UPC 12534 ti0.2�OR srCpNs�� N4iTiNGG,MN 3Z )Q No. Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes ZIpphration for Mtopozal *potem Congtruttfon Vermtt Application for a Permit to Construct( )Repair(&/)Upgrade( )Abandon( ) ❑Complete System l�Individual Components Location Address or Lot No. y _. / ' Owner's Name,Address and Tel.No. 7 Ij^ 15pllwv Assessor's Map/Parcel /'+ee ���/j� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 8IN-1/0/}1 7 71 JI 399 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(Agp Other Type of Building L°S i% iG No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1/9 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank At&_o �>19 Type of S.A.S. /,0 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7-lAe , 7 Ar g?l � 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 issued this B d f Health. / l Signed 9,0 Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No. Fee 7-1 ,•�wnrw+aiwirn., THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS r ZIPPrication for Migozar *pztem Construction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) El Complete System lJ Individual Components Location Address or Lot No J y®r,�L -le r Owner's Name,Add%ess and Tel.No. Assessor's Map/Parcel v Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. BD/'�G Cori GP'r9s�' 7 7/-11135Y Type of Building: Dwelling No.of Bedrooms r Lot Size sq.ft. Garbage Grinder(14/1� Other Type of Building e-3 Kre No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow d1�0 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) 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 issued thi B ardj9f Health. _ J Signed Date Application Approved by - Date 10 9 / Application Disapproved for the following reasons ' I Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System Constructed( )Repaired (" )Upgraded( ) Abandoned at l � ' C,— has been constructed in accor rice with the provisions of Title 5 and the for Disposal System Construction Permit No. J Z dated 9 Installer Designer d The issuance of this permit ha o/f b/ construed as a guarantee that the syste w/ll�fu�nction as de ned.� J Date i7{!n (�l of Inspector J V --------------------------------------- No. (9 �y 7 Z ( Fee jV �•► THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi!5poal &p.5tem l-ongtruction Permit Permission is hereby granted to�/onstruct )Repair( ))Vjpgrade( )Abandon( ) System located at el 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 thi e it. �/� Date: ��Z �/ Approved by_'� �/ alt�X�`'�' / TOWN OF BARNSTABLE LOCATION 17 /�'©/ j(�,�`�]` //1, SEWAGE # VILLAGE CeV�eLv111-2'2 ASSESSOR'S MAP & LOT /�y�y7 INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY /f'cv G4 C LEACHING FACILITY: (type) S/L' G�C Z-4//i,1L (�� (size) L-1 r:r ' NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: —��—Q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 Feet Private Water Supply Well and Leaching Facility (If any wells exist // on site or within 200 feet of leaching facility) �3 Feet. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ici 00 EJ i r� 10/9/97 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 ENGINEERED PLANS) I, Pe t i /P A( , hereby certify that the application for disposal works construction permit signed by me dated /ZS`�Q r , concerning the property located at 17 �/Oa�1�J���7``/l� meets all of the following criteria: V There are no wetlands located within 100 feet of the proposed leaching facilityThere are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed Y ere are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will w be located less than fourteen(14) feet above the maximum adjusted , groundwater table elevation. Please complete the following: —7 A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.cert V" l dcl- �00 O�V s I E� AJ a/L-+�-w sue" (A- S Q� / TOWN OF BARNSTABLE I O CATION 17 4 /01'4�7� d*I/ SEWAGE # ,�,LAGE'` CeV�G/v/Z/,1;1' ASSESSOR'S MAP& LOT /ff--"-y7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /rao C'e C LEACHING FACIL=: (type) S'io 0) (size)A,z yG',*,�1 NO.OF BEDROOMS_�n BUILDER OR OWNER OC ll Sy�� PERMTTDATE: 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) Ah, Feet Furnished by -107 00 'U TOWN OF BARNSTABLE LOCATION [(-W� LAB- SEWAGE # "��� VILLAGE °z�BLZzy�. ASSESSOR'S MAP & LOT.� INSTALLER'S NAME & PHONE NO. Q&er—Ca Sp, 2j: SEPTIC TANK CAPACITY «Op q=)ak ,tlqj LEACHING FACILITY:(type) Kc—C Acor p"r (size) -k NO. OF BEDROOMS—PRIVATE WELL O LIC WA R OR OWNER DATE PERMIT ISSUED: �Z:- DATE COMPLIANCE ISSUED: Zo "`'� VARIANCE GRANTED: Yes No �''� rre� � Scl ARMAD THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH igtl6dIsla D8t6 �-�.-...-.OF�j� 141f .G _ ,Applirtation for Bispvii al Works Tomitrnrtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ................----17: ....t�c �e..?:...s_..............%.e... ................. .. r...--------------------•---------...........-•----.....--- Location A dress or Lot No. .... �1,�,c �. r . C4.6. ..........-•.......................... •....-----. = . _ .......................................... ... �O eYz y R Address t�Installe Address Pq Type of Building Size Lot............................Sq. feet U U Dwelling—No. of Bedrooms___.._.....•...........................Expansion Attic ( ) Garbage Grinder ( ) Q Other—Type Other fixtures ---------------------------------- No. of ersons------------------------ ---Showers - C4 YP g •-•-•-••-••---••••-•-•-..-• P ( ) Cafeteria w Design Flow........."�}_3' ..........................gallons per person per day. Total daily flow.. 6.............................gallons. WSeptic Tank-L Liquid capacitylLVC1_-gallons Length... ........... Width---5........ 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 ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ 1 Test Pit No. I...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 4 0 Description of Soil........................................................................................................................................................................ x U ---•--••-•------............................--••--••--••-•-••--•--•-•--•----•--•----•---•••-•-•---•---...---•--•-•--•-•....--••----------•-----•--•-•-••--••-••---------•-•----------------••......•-- w U Nature of 4epairs or Alterations—Answer when ap licable...._- &5, _�r�-`:- S__ e ------------- t --•------- ------------------------------ ----------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITA U 5 of the State Sanitary Code—The undersigned furt r agrees not to place the system in operation until a Certificate of Compliance has been issued b h of hea igned ---- ------ --- ------- - •-• r. -•--•---=--•-•-••--••-••----•-•--• �:.�i'..7......... r � � Date Application Approved B !�.. .. 1 -�" � ... _. ---- ........................ ------......Date 7 Application Disapproved for the following reasons-------------------------- ----------------------------•-----------------_----- - •---•----•_--- ................•--•••---•-•-•-•------•------•-•-•-••------•---•---••--•-----••--........-----------•••-----------•-----•••-------•-•--•-•----•----.-•--------•----................................... •_••Date Permit No...... { .........................r ssued.--•----�I gi Date a NO.. C.......:.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �TC7..1....... ---.....OF. 1 .<. .......... ............ Aplifiration for UiovooFal Works Tonolrurtion runfit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ................-.4.-.I.....1.L2s .� .............................................. Locat' -4d ess pr Lot No. D:n W a .. � /l JQwn ._ �, _F.Addre�n .............. jJ ............................. .....--------------•---.�..�.....-...._........----...................................................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_3.....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -• ----------------•-••----------•---....--------•--••-------•--•---•-------- W Design Flow............... .5........_....._gallons per person r day. Total 'ly flow..� _.1........................gallons. WSeptic Tank l Liquid ca.pacity.��.gallons Length.... Width.. ........ Diameter................ Depth................ x Disposal Trench—No. .................... Width_..:.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No ............. Diameter.... __.__.....3 �� Depth below inlet_.!.............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I_____-_____---minutes per inch Depth of Test Pit.................... Depth to ground water........................ P= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---•------•-------------•---•-•-----••-•----•-•---••-----------------•--••--------------•----•-----------------............................................. 0 Description of Soil........................................................................................................................................................................ W U •---•--------------••--•----••---•-----•----•-•-•-•-••---------•--•------•--•-••-•---.......------....-•••••-•-----•-----------•••-••••-•-----•-•-•-••---•---••••••......_......----...........--•----- W x -•---------------------------------------------------------------------............................................................... ---------............................................... 0 Nature of Repairs.or Alteratio —Answer when pplicable_��` -� :�. ....16 ..5-kpt -TAc --..... -----.....•• "L�1E---------- -P 4.7_11-]=��- *tru--�e ............................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i b t e board f health. Signe ..... -----•• . --................... ............•••--•........ _.... _ �/ to Application Approved B �.. r !�pr/ fit..".� ."> . E Date Application Disapproved for the following reasons:......................... -------------- ................••-••--•-•--•-•-•--•-••-•--••••-••-•----•••••--•-••--•--.......••-•-•---.._._...••••-•--•..-•--•-•--•-••••---••••-•--•-•---•--•---•----•---••••••••--••----------•••---••..._--•-•------- _ Date Permit No...... .. t Issued_......... ' -----•-- -••------•----------------- .----Date--------._...r .---------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........`......T-.10! '.......OF..7.Y; �-T�t`d' ........................^.: _. Tatifirab of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by .._...... G=' � � !!Q.. C.r------------------------------------•------------------•-------.......-•----.....------......... • Installer at.. 1`7 .S-- ................................................................................................ has been installed in accordance with the provisions of TA�T, of The State Sanitary Code as described in the ` • application for Disposal Works Construction Permit No .._..a_._ ....•__..•.._ dated.. ............��. " ....._____. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .� No.......i................. FEE ...:....`�....... 11iopooal o ko Tonotrudion rruti# Permission is hereby granted.............. ............................................................ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System ` atNo......................................4-7-------4Lo-f � _�'`e ..�as-z,- �..........................................:_---� --....�... Street rr � as shown on the application for Disposal Works Construction Permit Z _.,_._. Dated ---------------------- ----•-------..... � � � Board of Health DATE........ ................. FORM 12-55 A. M. SULKIN, BOSTON