HomeMy WebLinkAbout1025 OLD STAGE ROAD - Health 1025 Old Stage Road
Centerville
A 172 160
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TOWN OF BARNSTABLE
1:6CATION,ot-5 0/0 V,4� ��, SEWAGE#A0/� 03
MY LAG � _�/�'/ ASSESSOR'S MAP&PARCEL4
INSTALLER'S NAME&PHONE NO.c�W �A7,�"
SEPTIC TANK CAPACITY /&VO �Q!!
LEACHING FACILITY:(type)y� 604 f¢e) I
NO.OF BEDROOMS
OWNER k°/se"V �C,'°4 1 V-e s
PERMIT DATE: 7 3 / 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) Feet
FURNISHED BY
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01
NO. 3 —7 THE COMMONWEALTH OF MASSACHUSETTS FEE'I/k/rj
BOARD O'F HEALTH
APPLICATION FOR DISPOS SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( pgrade ( ) Ab don ( ) - ❑Complete System ❑Individual Components 00
Lo xio. O er' Na t
M /Parcel#
yI
�,A n(�l`• ' Lot# �y Tele e# '
�IGLJ �lA 1 f
Installer_trne —17esign—er`sNarne
Addres Address
Telephon4# Telephone#
Type of Building: P z1 Lot Size Sq.feet
Dwelling—No.of Bedrooms B '�, r u ���� pvr^4abage Gri der11
( )
Other—Type of Building No.of persons j Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(mi4 requi ed) 0: gpd Calculated desi n flow gpd Design flow provide gpd
Plan: Date b 1�B1 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
c., 1
DESCRIP ION OF REPAIRS OR ALTERATIONS �� � ✓ W
The u4furth
agrees to in tall the above desc ' ed Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 arees not to ace the tem in o anon n' a Certificate of Compliance has b en iss d by the Board of Health.
Signed D DateInspecti t z /
IF
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. THE COMMONWEALT O MASSACHUSETTS FEE
BOARD Ojj� DEALT-H
W
' 1 UW1Nl �- ✓
t
`APPLICATION`FOR DISPO�pgmdc
SYSTEM CONSTRUCTION PERMITMIA
Application for a Permit to
Construct ( ) Repair ( ( ) Ab don ( ) - ❑Complete System ❑Individual Components
t�
� Lo do O ner' Na �
Mt/Parcel ft
Tel: e#
Y`�1L I�^.tKI �ler'sN�me + e s i g n-e-r-M ame
9l�T� F
Addres Address
lephon # `- Telephone#
R , �
,r Type of Building: -��'.J" Lo Size 15,Q2n Sq.feet
Dwelling—No.of Bedrooms �r a bage Gri der ( )
Other—Type of Building No. of persons -Showers ( ), Cafeteria ( )
Other fixtures
r
Design Flow(mi requi ed) gpd Calculated desi n flow gpd Design flow provide gpd
Plan: Date b 1.0 Number of sheets _ Revision Date
Title\
Description of Soil(s)
-Soil'Evaluator Form No. Name of Soil Evaluator t� bo e, Date of Evaluation
DESCRIP ION OF REPAIRS OR ALTERATIONS l�� C7 ✓ L�� l �1� �
The undersigned agrees to in tall the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5��nd forth' agrees not ro ace the tem in o anon n' a Certificate of Compliance has b n issu by the Board of Health.
t
Signed Date I �D
Idspec ns '
a `
X
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
- - -
No. �dl) - 03 / HE COMM N EALTH OF MASSACHUSETTS �__-�-_ � � �� ����FEE lI
�U _.
BOARD OF HEALTH
CPKTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑Complete System
The undersigned hereby certify that the
+Sewage Disposal System;Constructed( ),Repaired(�raded( ),Abandoned( )
by: C�9)W �C , GOW 5T- ',
at t 02,s� Oup w'1tom(
has been installed in accordance with the provisions of 3 0 CI\ R 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. ad/S-037 2z dated 2 ' 1 Approved Design Flow yU (gpd)
Installer CV tU L!J)Vl �(Jll t�
Designer:_�P, Iy l � Inspector ^
The issuance of this certificate shall not be construed as a grantee that the system will function as deiignej.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
-_:.___„_.,.•_,ti.--._,.,.r.__�__,.�.,._..:'.,._...-_•..,-.�,_;.,.�.��-�:.�.�,�-:..._-.��.�-Y:.�:..,-:�,�-_mod-��,�:--. �;�
No. ll I D3.7 THE COMMONWEALTH OF MASSACHUSETTS FEE / O0
/' BOARD OF HEALTH
DISPOSAL SYSTEM CONST CTION PERMIT
Permission is hereby ranted t Cons t ct ) Rep it Upgrade ) Aba don ( ) an individual sewage
disposal system at as described
in the application for Disposal System Construction Permit No. a ,)1 LQ 3..7 dated 1 1 / t'
Provided: C(onstr ction shall be completed within three years of the date of this p it. J11 local onditions must be met.
Date �. /2 3// Board of Health �, J
FORM 2 - DSCP DEP APPROVED FORM 5/96 G
FORM 1255 (REV 5/96) H&W HOBBSB WARREN'm PUBLISHERS- BOSTON
Town of Barnstable
pp THE T
ti Regulatory Services
Richard V. Scali, Interim Director
• BAMSUBLE,
9 MASS. Public Health Division
i6J9• ��
ArEo►��° Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
1� Installer & Designer Certification Form
Date: 1Sewage Permit#;(]/<- 03 `] Assessor's Map\Parce1� 72 /to
C
Designer: Installer: 1
Address: �_ �h��)�� . Address:
On (ins alter was issued a permit to install a
(dat
septic system at OLP based on a design drawn by
(address)
dated j
designer)
I 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. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major 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 Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed nce with the terms
of t e IAA approval letters (if applicable) ��A 0F41,��i GoJ, �s
-..
AVI
B.
sta e s-Signature) (� i�IAS�N 1
l v tdo.1066
(Des gnature) (Affix Desib p&, p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
I
I, zo (OltA-k owner of the property at
1025 Old Stage Road, Map 172, Lot 160 do hereby verify
that the dwelling at this property has been a four (4)
bedroom dwelling since or prior to July 4, 2008 as is
depicted for the purpose of the septic repair design on
.the plan prepared .by-David B. Mason, RS dated January
16, 2015.
Signed on this day a 13 116
Owner;
Town of Barnstable P#
Sx
Department of Regulatory Services
c &UMSTABL4 Public Health Division &A Date
e �a� 200 Main treet,Hya5Os MA 02601
Date Scheduled Time Fee Pd.
r r
Syys� l uitability Assessm t for S"ei �Performed BWitnessed By:LOCATION&GENERAL INFORMA /W^�/y�
Location Address Owner's Name Ih A /
yyy 1 �j'y`C��"'' Address
Assessor'sMap/Parcel:/ / �1'%i��) Enginem'sNamecfi'/7
NEW CONSTRUCTION / REPAIR (� Telephone# 60 —3a74
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
XZAVT
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 soil 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
PERCOLATION TEST Date Time
Observation -
Hole# Time at 9"
Depth of Pere Time at6"
Start Pre-soak Time @ Time(9"-6")
End Pre-soak -�
Rate MmAnch `
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: 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 Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
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
� I
LIV
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Graven
I
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Graven
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
' Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
• Consistency,%Graven
Flood Insurance Rate Mao:
Above 500 year flood boundary No ///yes
Within 500 year boundary No,,V/Yes
Within 100 year flood boundary No✓ Yes_
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pe i terial exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth f na lly occurring pe ious material? _
Certification }/�
I certify that on lw (date)I have passed the,soil evaluator ex ation approved by the
Department of Enviro en 1 Prot ction and that the above analysis was pe rm d by me consistent with
the re ing,e p l d eri ce described in 310 CMR 1:5 7
Signatur Date
Q:\SEPTIC\PERCFOPM.DOC
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DATE PERMIT ISSUED I
DAT E COMPLIANCE ISSUED
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Df
N 7.... l... ... Vim..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF,, H A THE R
W rV
�D Appliration for Dhip s ai Works To' nstrurtiun ramd
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
/n.4.1 ...........
, ----
cation Add re or Lot No.
...........b SEI._�W..'.. . .... ................ ...... ......
1.4
Owne � � Address
r,
Pq Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (�� Garbage Grinder ( )
'4 Other—Type T e of Building A4-7,.""�....... No. of ersons...... 1 p,, yp g _.. .__ p ,,�................ Showers ( ) — Cafeteria (.
04 Other fixtures .................................
Design Flow...........5 :r.....................gallons per person per day. Total daily flow...,R�R.Q-..........................gallons.
WSeptic Tank—Liquid capacity�-APO.gallons Length___-A5�...... Widthe-K.......... 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----------------- iQ.s�. __..��5 .�............. Date......
W
Test Pit NCO--------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
Lt, Test Pit No. 2................minutt`es per inch Depth of T t Pit.................... Depth to ground water........................
pt �n �- � r0D iio ------ - -----
WV ...................................••--- ----------.......--•........--••.....- -------•-----••-•-•-----------------•------------•---------•----•-......------------
U Nature of Repairs or Alterations— wer when applicable_..........
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 agrees not to place the system in
operation until a Certificate of Compliance has bee ued�. yb 2e boa 1
gned .•-- / --- ---------•----------••------••----- f _l 7.
Date
Application Approved By---------- .........................•••. _..............:-
D ate
Application Disapproved for the following reasons:._.. ----------------------------------------------------
-•.................••----...-•-•------------•------•------....---....----•-------............--------•---'---•----------------------------------------------------------------------------------------•--
Date
PermitNo......................................................... Issued.......................................................
Date
NV .......... .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD (?F H TH
OF......
. ....................... . ................................................
Appliration for Disposal Works Tonstrurtion Prrutif
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at
....... ..... 4��t2A�.r.....................................
...... ...... ........................ ............
kcatio or Lot No.
.....
do,ve�................................ .....................................................I............................................
fOw Address
..... ......
W 4 j;./ e
............. -------� ?., I - --------------------------------- ..................................................................................................
4 Installers Address
Type of Building Size Lot--------_-----------------Sq. feet
U
Dwelling—No. of-Bedrooms-' Attic to`10*" Garbage Grinder
9 7....Z ...........................Expansion-
P4 Other—Type of,puilding ........... No. of persons__---A................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
15 .3
Design Flow.........*A CA 0....................--gallons per person per day. Total daily flow—R-ARM...........................gallons.
1:4 Septic Tank—'Liquid'capaci)lg.i:.Pg..gallons Length---1K......... Widt4$..'0............ Diameter................ Depth...._..._...__.
Disposal Trench—No.'.................... Width..................... Total Length.._.........._...... Total leaching area....................sq. f t.
> Seepage Pit No........___. Diameter.................... Depth below,inlet_....__ ....._... Total leaching area..................sq. f t.
Other Distribution box Dosing tank +
64%4 Percolation Test &esults Performed by.............. ..... .......- .............. Date____ 10-4-1218----
Test Pit No-----------------minutes per inch Depth of Test Pit......................Depth to ground water--___-:__--__-__---_-__.
f=, Test Pit No. 2.-.r......"4..-,...min%es per inch Depth of T ................. Depth to ground water._____..................
,/st Pit
.........4 ox-; Ae ek j
tion - ---------
0 D soil....P.—.A......... - --------------------- -- ..
rip...........4..... ..............................................................................................................................................----------------------------------
......................................................................I......... ---------------------------------------------------------
-------------------------------------
U Nature of Repairs or Alteratio �AVscwe'r whet! applicable.--______- ............................................... .................................
........................................ ............................................ ........................................................................................................
Agreement:
The undersigned.agrees to, install the,,afor.6deAkribed Individual"Sewage Disposal'System in Accordance with
th6'6'provisions of TI TAIL, 5 of the State Sanitary Code—7The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee rllpsued/It bo Zbo 1b..g
igne ...... ...... e.0 P.8
...... ..........
.... .............. ....................................
ApplicationApproved By......... . ....... ............................I............................................... .......................................
Date
Application Disapproved for the following reasons:................................................................................................................
................................................................................................................................................................................I........................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_OARD OF LTH
........................................
. ..................................60 F.............. .....................................................
Tntifiratr of Tompliaurr
TIJVIS TO CEJ?;WFYIFhat the Individual.Sewage Disposal System constructed or Repaired
by......0......4.-*,//A..-1, .............................. ...................... ...... ----------------------- -------------------*------------
_ ...... ----- ..............................................................
slall
.......... 4r I A
at............ ............... .. ...... .. .....
has been installed in accordance.with the provisions of TITLE JJr of The State Sanitary Code as descri�� the
application for Disposal Works Construction Permit"No.........
...
7---------------_ dated__ .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS-A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................................................................... Iiispect4...............
---------------------------------7----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O' HEALTH
/
OF..........4�u.. 7-
................................... .......................
7 ..............
......................... FEE,1?J.............
Permission is hereby granted....... .. .......... ....................................................................................
-----------*...........
to Construct or Repair an Individual Sewage Disposal System
atNo.................................................................................................................................................................................................
Street
NI
t
a
0
t
as shown on the application for Disposal Works Construction Per Dated-------------
.............M-- ------------------- --- _- --- ..........
DATE....... .
7" oar of
Health
. ................
FORM ORIVI 1255 HOSES & WARREN, INC., PUBLISHERS
vrove
VIA
t,yr.::
I
1
ASSESSORS MAP : �7Z—
TEST HOLE LOGS:
PARCEL :
13 �� -- - — - ___ . ----------- I ,An" I) The installation shall comp Willi "Title V and Town ot�Nut�3oard of.
;., FLOOD ZONE: ��T ��PG/�" SOIL EVALUATOR: 1/ e. IVtI�
-.---'� �_ Ileallli Regulations.
I ,
_ ! — _ _ 2) The installer shall verify (lie location of utilities sewer inverts and septic
REFERENCE: WITNESS :
b I Y
II °� �- +f �� � Z� DATE: J P0AJ 0 IZ cn components prior to installation and setting base elevations.
•- — p 6
/ PERCOLATION RATE < 2 l 1 . 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per root. The first
6 /
PAN
,�SZ _.! v, Z- Y� / 1� two feet out of the d-box to the leaching shall be level.
TH- I THZZ 4) This plan is not to be utilized for property line determination nor any other
purpose other than the proposed system installation.
A 0 *00
5) All septic components must meet Title V specifications.
�� I 6) Parkin shall not be constructed over 1110septic
! g components.
JV 7) The property is bounded by property corners and property lines.
���i t t �� 8) The property ownier shall review design considerations to approve of total
LOCATION MAP '� , . pa
+: design.flowlatid number of bedrooms to be considered for design. Receipt
i L I��� 5 <� lv� I! � of payment for the plan and installation based on the plan sliall be deemed
approval of,itie design flow by the owner.
E ;
��l��IL C• 1���1 9) The existingi leaching or cesspools shall be pumped and filled with material
I ..
per Title V abandotunent procedures. Those within the proposed SAS shall
,i be removed along with contaminated soil and replaced with clean sand per
Title V specs:`:
l0)System components to be 10 feet from water line. Sewer lines crossing the
waterline shall be sleeved with 4 inch SCI140 PVC with ends grouted if
applicable. The proposed SAS is being installed,below the water service
57
line. The line is to be sleeved as aforementioned and maintained in place.
I ;, � �--- ir\ J6 �� _� S E P h I C SYSTEM DES I GN 11) If a garbage grinder exists it is to be removed and is the responsibility of the
+.:I v� , -�� 3 3 , _— owner to ensure such. -
1 FLOC! ESTIMATE 12)The installer is to take caution in excavation around the gas line if such
exists:
t BEDROOMS AT I I O GAL/DAY/BEDROOM -�`I b CAL/DAY 13)The installedshall verify the location, quantity and elevation of the sewer
lines exitik0lte dwelling prior to the installation.
I (�" 14)This plan rs epresentative only that a system can fit on a property nieetin
i SEPTIC TANK p p Y g
Title.V requrrenients,
/ 17 GAL/DAY x 2 DAYS - GAL
US1: I DOS GALLON SEPTIC TANK (EiKV11 t+
I -- — — SUTL A8S0APTION-SYSTEM ---�-- - --- —
Vl I �- `"a
I �
s ,
3 DAVID '
SIDE AREA: Z� �,� -f- �Zr'� �CZX r� � / 7
-1 IVIASor� n;
O BOTTOM AREA: IZI = 0
I - Q
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�, � No 1066 0
/qeel
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E SEP— I C SYSTEM SECT I ON0-5
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