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HomeMy WebLinkAbout0258 OAK STREET (CENT./W.BARN) - Health (2) 258 OAK ST., CENTERVILLE A=193-170 �ll/1 3, UPC 12543 % a Now HASTINGS. MN 0 J No. " �!/ Fee 25 ", C� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Mi5potal *p5tem Construction Vermit Application for a Permit to Construct( )Repair(Kupgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 58 0 o k S% Owner's Name,Address and Tel.No. t"Rl SA T6 cfvAyao_ ayve Assessor's Map/Parcel C�// a F8 0 Pr Ix 57; is — / CG'A/TC2-+'//T Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Go2oon3,r�.Pus ,2/S- OsT—w•B�Rn•�co` os icr,.t,II C, Rn , 0� 4 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 Type of S.A.S. Description of Soil � s i r Nat re of Repairs or Alterations(Answer/when applicable) 6�IJ 3" C c 33 D S v22u v-v,a h r 3 S7-04 e 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 iss d by Board o this f Heal Signed vCc Date A67 �% B Application Approved by i Date '� , Application Disapproved for the following reasons Permit No. "= , Date Issued TOWN OF BARNSTABLE LOCATION 1Z b L �Q1C �' SEWAGE # `TILLAGE yPeZW41;//'-0 ASSESSOR'S MAP & LOT& ,®DIOD( INSTALLER'S NAME&PHONE NO. �7�2�'`'/� SEPTIC TANK CAPACITY `Z 9 AA / LEACHING FACILITY: (type S (size) NO. OF BEDROOMS M n BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: �'�®�' r 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 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 r �� LdCATiION `� SEWAGE PERMIT NO. G d fig'- /97 VILLAGE IN.STALLER'S NAME a ADDRESS ?z B U 1'L D E R OR OWNER TT DATE PERMIT ISSUED D A T E COMPLIANCE ISSUED �2 � ,- r 3i �� No. " V Fee [J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: a - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS— 21pprication for Migpogal *raem Construction permit Application for a Permit to Construct( )Repair((/Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ` S p 0 R k S%. Owner's Name,Address and Tel.No. L Assessor's Map/Parcel l r`� �?`'' 8 0 A h ST i;T-- I rrlp 014::' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Gt72oon 1�. ,4pvs- ` 0s7-c.•3,42n•A01 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 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)A 0 D 3 — C'L/%e r 3 S D S v 2/?0 v a ro �� 3 roLr2.yl 6, 3/d 0c1A S'roV1 e 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 issu d by this Board of Heal . Signed _ - Date a a Application Approved by Date w✓ � ,�, SI Application Disapproved for the following reasons Permit No. Date Issued •° THE COMMONWEALTH OF MASSACHUSETTS 1 BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance �,, .�; THIS IS TO CERTIFY,that the On Sewa,ga Disposal System Constructed( )Repine (' Upgraded( ) Abandoned( )by VA/ Sin%rr_e,14 ,41, at OA S?. ('F fZF2-,%lr4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. w dated �— Installer_01--c c r//d cA/1)%2 Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date : Inspector ———— ——— — Fee �"�-»•^� No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1Wi9;po.5a1 *Pgtem Congtruction Vermit Permission is hereby granted to Construct( )Repair(`%f Upgrade( )Abandon System located at ,9S6 Or1 A S% A 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 it. Date: Approved by Cf.'; ° a C2 ro19W NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION HOUT OR A DISPOSAL WORKS CONSTRUCTION PERMIT (WI ENGINEERED PLANS) °hereby certify that the application for disposal works construction permit signed by me dated concerning the property locat ed at a O H S CF T/�v°�/F meets all of the following criteria: e There are no wetlands located within 100 feet of the proposed leaching facility e There are no private wells within 150 feet of the proposed septic system e There is no increase in now and/or change in use proposed e There are no variances requested or needed. e If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will n91 be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: 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)L8. 1�o. 0 DATE: a� SIGNED: LICEN D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed Installer poseaaes fa certified plot plan, this plan should be submitted). q:health folder:cert d Ij- CC C� �flCh O�/70�s� b C XIS 1��\S I�Oco�ra�. i 1 �oj TOWN OF BARNSTABLE 2 LOCATION a?T8 OAL S 1• SEWAGE # Y'O ,-3a J VILLAGE Ce.nTe c-L1 C, ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. 4 a8�S6 4 0 SEPTIC TANK CAPACITY /i000 G'A/. LEACHING FACILITY: (type) (01 CC 3.30- — C3) (size) NO.OF BEDROOMS BUILDER OR OWNER VAS SAr, 0,09�A PERMITDATE: IlA � /928 COMPLIANCE DATE:Sri 1!e Y? _ 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r TOWN OF BARNSTABLE L LOCATION o2l? OR h • SEWAGE # P P 3 VILLAGE ASSESSOR'S MAP & LOT1,93—IM INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /Z000 LEACHING FACILITY: (type) C(,mcc 330s — C3) (size) /O Xa,9 / NO.OF BEDROOMS BUILDER OR OWNER I/A` Soh a�c A PERMITDATE: I"I4yo2b,199 COMPLIANCE DATE:�ri 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 G p,Qas� a56 S�%Anh o27� a6 LeAc k % 7 4y '6 i 1 o?'7 356 9isl$ox 3�/' �. a6 ' LeAck I':l 44.6 y, ,,�rc,1rc ye ' No........ Fics....rS Uv....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....... ... .... ................OF................................_....... ..._........... Appliration for Ui_qpnsal Works Corm rurtinn Prrutit Application is hereby made for a Permit to Construct k) or Repair ( ) an Individual Sewage Disposal System at: Q - ........C�� ....' :.................................... ........................................................... Location-Address or Lot No • �� ..�L e ! '! � ........................................ N o. �� .. .!eu�....-�.�sT2.4------------------- ---- ---$19 ....---•- . ........----•--- O ner Addres / r-&49 t..................................••-----•-------- --L'��c�,ag- --C. ..........................?�..... ............. Installer Address Q Type of Building Size Lot...l�,.A.Z�.._..Sq. feet Dwelling—No. of, Bedrooms............................................Expansion Attic (fit/ J Garbage Grinder toe? aOther—Type of Building p ( ) ( )�Ar!!L`_`t_...._____.. No. of persons �_____________________ Showers 3 — Cafeteria Otherfixtures ...............................................................------------------------------------------------------------------------......-------- W Design Flow..........&10..........................gallons per person per day. Total daily flow................... ®..............gallons. WSeptic Tank—Liquid capacity/060..gallons Length................ Width................ Diameter.....±'......... Depth...4........ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........1-........ Diameter.1_:S- ------ Depth below inlet......6_`......... Total leaching area..................sq. ft. Z Other Distribution box (4--) Dosing tank ( ) aPercolation Test Results Performed b ..OAPc.e.... __..._ ____.. Date.... r.I6.:'7�.............. Test Pit No. I................minutes per inch Depth of Test Pit......&f .___. Depth to ground water--__� 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------.................. f 04 ---------------------------------------------------•----••-----------...............................•-----....................----...----......._.........._. ` O Description of Soil--=. `'q.y.....���' �'l�J�---------------C��"`.....°h--- !" �' : .._ I 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 iITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...f�'�",. C. ..... ------------------------------------- Date Application Approved By....... �C.....:................ Date Application-Disapproved for the following reasons--------------------------------------------------------------------------------------------------------------- ...........................•---•--------...........------------•----------------...-----------•-------------•--------------------------------------.................................................... ....Date PermitNo......A.7.---------•-•---•--•-•............................................ Issued........Y.- `- . 7 Date' No......................... < FEB V-4 ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................... Alipfiration for Disposal Works Tonstrurtion "primit, Appl>cation is hereby made for a Permit to Construct (I-, ) or Repair an Individual Sewage'Disposal System at: ...........•*........... ----------- --­-------­----- ................................................................. Location-Address or Lot No ................... .... ......6 ......Z-70?..................................................... ........................ Owner Address 41'�6 4- Installer Address Type of Building Size Lot_.?%,.A2� .....Sq. feet U Dwelling—No. of Bedrooms____.: 1_..___________________________Expansion Attic V/4 Garbage Grinder Other—Type of Building ............ No. of persons___ ..................... Showers Cafeteria Other fixtures Design Flow........../.!/0..........................gallons per person per day. Total daily flow................. . ....... ..............gallons. 04 Septic Tank—Liquid capacitye,.6L.gallons Length________________ Width__.__._________. Diameter------?,........ Depth_­51......... W - Disposal Trench—No_ ____________________ Width_._.__.__._.__._._.. Total Length..___._____.________ Total leaching area....................sq. ft. Seepage Pit No.______.-./........ Diameter..�E..4;........... Depth below inlet__.._ ............ Total leaching area...................sq. ft. Z Other Distribution box (4- ) Dosing tank ( ) Percolation Test Results Performed by..____67-- ,�.4---- - --- Date..... .............. �--j ------- ----- --- -- ----"......--------------------"------- /Test Pit No. I................minutesperinch Depth of Test Pit_.___.. Depth to ground water- f Test Pit No. 2................minutes per inch Depth of Test Pit__.___.._._________. Depth to ground water_.______.______.____.._. ............................................:I............................................................................................................... 0 Description of Soil----. ................ ..............M.... ...e_�.q......./...0..... te-/ �4 .................... U ......................................................................................................................................................................................................... W ........................................................................................................................................................................................................ �4 U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ..................................................................................................................................................................I..................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'"LlITI-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.. _!�—------ ------------------_--------_...... Date ApplicationApproved By............7, ....................................................................... ...................Date.............. Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......19.7........................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ..............OF......... jr*,44&. ............................................................. (Irrfifirate of Toutpliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by............./.U.VA" IY14&e f ......................7............................................................................................................................................... Installer at----------- - --1-------- ........ ............ 2v-4 A- P I't.------r- ......0..................................................................................... has been installed in accordance with the provisions of, TITLE 5 of The State Sanitary Code aid5cribed in the application for Disposal Works,,N&fruction Permit Na "j, .................... 7f ---- dated_ -------------------- I---- ------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.il ............................... Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS .4- BOARD OF HEALTH ..........................................OF.........*.#A,-J P *,At ......................................................................... No........ztl...... FEE..... ....... Diaposat Works T-FaInstrurtion "rratit Permission is hereby granted____._____ .....ZY2.,.14---(f..V.................................................................................... to Construct ( X) or Repair an Individual Sewage Disposal System atNo.............L.6.,'......... .......... ...... ..... C...... ................ ...................................... .................... Street as e is os shown on the application for D`�­'al Works'C6nst mit --- .. ... ....... ......... ........... p ------------------- ......................... ............... ..... ................................................. 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