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HomeMy WebLinkAbout0291 PHINNEY'S LANE - Health (2) E= 230 nney's Lane 010 S UPC 1253.4 No.2-15�3LOR HASTINGS,UN I P TOWN OF BARNSTABLE LOC,iTION �// i�v^� S LA41z- SEWAGE # a V 0 'Sfjy VILLAGE GaFna?� uiL1E ASSESSOR 'S MAP & LOT 930-0/U INSfALLER'S NAME&PHONE NO. /9 /3 l"i4�1lGvia SEPTIC TANK CAPACITY / LEACHING FACILITY: (type) (size) NO.OF BEDROOMS Ce-- /VI,4/w _.BLUDER OR OWNER / PE,RMITDATE: O COMPLIANCE DATE: 1 U 'Z`l—0 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 �jAcle a != �.�ov s i �• y. �Si fi a �� � � � � I u P�K Q c. ���voL ,�� , TOWN OF BARNSTABLE LOCATION 0 7 I SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO._ � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) t0�' NCI. OF BEDROOMS PRIVATE WELL. O _ UBL1C WA BUILDER OR OWNER c o u DATE PERMIT ISSUED: •-- DATE COMPLIANCE ISSUED;_, l sl VARIANCE GRANTED: Yes_ No b No. C!0 FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, 9,4 1P MA. APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTI®IN PERMIT Application for a Permit to Construct( ) Repair(L�<pgrade( ) Abandon( ) - ❑Complete System &Individual Components Location IAIAf F v' i�rt- (2�ti�- Owner's Name ®� —J- /V Map/Parcel# 2 3 U s o l o Address a y� PVW 1A14'F i'Y I-A, e rX,7- Lot# Telephone# Installer's Name C CJ Designer's Name Address �d J 7 4v_ S Vxl Address Telephone# .�C3 - S - r Gy-V Telephone# Type of BuildingU✓-5 Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria O Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS / C 1,;�Jly IA/ Ai, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agns to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Jo 02,9- ,,k' Inspections No. G 0, FEE / 04 V COMMONWEALTH OF MASSACHUSETTS Board of Health, W /Y /� - MA. J APPLICATION FOP, DISPOSAL. SYSTEM CONSTRUCTION PERMIT ���/ 0, Application for a Permit to Construct( ) Repair(4o) UpgradeO Abandon( - ❑Complete System J"Individual Components Location 0 j/1/A/f yy Ake Owner's Name C ocV 74 n/ Map/Parcel# Z 3 V U '() Address .29l P0,41 flvk f 5<x I-its C rx,7— Lot# Telephone# Installer's Nam �(,� e G Designer's Name Address *3 5O S 7 �_ Address Tel phone# y- �►/�� S - r dti Telephone# ,t,/a us Type of Building Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date °M Title Description of Soil(s) y Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS /P C IV/q w Al xJ The`undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es to not to place the s em in operation until aCertificate of Compliance has been issued by the Board of Health. Signed r Date Inspections !� No. ov ,s FEE ate— COMMONWEALTH OF MASSACHUSETTS Board of Health, _6,,d eA, MA. CERTIFICATE OF COMPLIANCE c G� owl Description of Work: tI Individual Component(s) ❑Complete System The unnde`r/signed hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (A+rUpgraded ( ),Abandoned A ( ) at 917/ ?///P Al f �S 1.M C has been installed in accordance with the provisions of 3310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to applicatio No CO1 `5 9 dated /U' -C Y.. Approved Design Flow (gpd) Installer a 411 Designer: Inspector: to .-/ 1��• Date: l o e�CI d LI 1 ( r The issuance of this permit shall not be construed as a guaran ee that the system will function as designed. No.2 U y Y !J 0 V FEE( (" Board of Health, 6,4 1,P 4,- MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permissions is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at � // 01 1 ti'N -$T / )N C Fkr as described in the application for Disposal System Construction Permit No.2 Uo y-ff , dated - Provided: Construction shall be completed within hree years of the date of pe' rrriit. All loP 1 nditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date U�)�/�L� Board of Heal b11\1j f C r TOWN OF BARNSTABLE LOCATION &� �5 IAN SEWAGE # VII,LA ASSESSOR'S MAP & LOT-3Q-010 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type (size) LACe' /,1,4I/V Lino = NO.OF BEDROOMS BUILDER OR OWNER ` PERMIT DATE:�/'/�' 9- COMPLIANCE DATE: Separation Distarce Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching.Facility 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 Feet within 300 feet of leaching facility) Furnished by i Hov S i l9 _ ay - - ------------------------------------------------------------------------- ---------------------------------------------------------------------------------------- ------------- THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH U 7�WNOF EAR NSTAa APPLICATION FOR DISPOSAL STSTEM CONSTRUCTION PERMIT Application for a Permit to Coristruo Repair Upgrade 41) Abandon C1 Complete System [JIndividual Components ?h) N!RITS L N 0 M NR PAI'MY F Z_iz / LOM Irl"j, 'E�V -FMINIT ENr`�S L N, 11 j U Aj�q I I M I K-LUS W EEMEY Installer's Name i 8 Ri •IN W1 a 1A 71 c� 111--"M'1+7 Telephone It Telephone'll Type of Building: DWY-L L J.N 19 Lot Size 0,-Z I Ag"t Dwelling—No.of Bedrooms 3 Garbage Grinder ( ) Other—Type of Building -No.of persons Showers Cafeteria Other fixtures DesWip Flow(min.requ gpd Calculated design flow gpd Design flow provided gpd P Number of sheets Revision Date A Title U.40- tj-C Sj�SMI f- G R&C-L4�Cj 771-�jj,, Description of Soil(s) Y Soil Evaluat ' ForJFk Evaluation I -oil Evaluator - of DESCRIPTION F NY I NS _jW A. The and above des;ribed individ ual Sewage pjsP0*ql System In qc;Qrdcmce with the provisions of TfffRUE 5 and aer"s W!q .111 Cimficate of Compliance has been issued by the.Board of Heahh. the syshitin in n Signed Date A C1) Insp tions--- FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 —————————--- -ram�x,r, z r s^sn '#° v..s;~ t§ `'f"`t'z:rs 4 wN': .�„,•z'�2 Ay,+;,e t.g••n ,— t 'x w _ r`No4c :THE COMMONWEALTH OF MASSACHUSETTS FEE �V ' BOARD O 1-HEALTHY �- APPLICATION ION-FOR DISPOSAL SYSTEM CEAR ®NSTRUCTION-PERMIT xL x APpllcation fora Perrin.w(unstruct ( ) Kip ur ( ) Upt ntd� (O I—Ali i�r"�don (_ j O Complete System ~�Indtvidtial Components, ' zoo � �� �-�;,��,�;.IPh I L Ak M 1 KLLoS W C. E.M EY hisu:ller'aNamc E �� �tiZ-b9• 1�14 T11-II S '9 4+7 Telephone it Telephone N Type of Building: QWr 1- L 1 N I Lot Size Z Ai t�t Dwelling--No.of Bedrooms -3 Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Desi Flow(min:re uire 3 3� d 3 gpd Calculated desi n flow T —gpd Design flow provided 7J' w gpd Plan: Date Number of sheets Revision Date _ FJ A Title Si< DL51GN Description o Soil(s) o�' S�tSTaI�C )�'4Q� C�A�IDSTdI�It CRAWL 'JW", Soil Evaluator\For `�I _ oil Evaluator of Evaluation 7' DESCRIPTION F P I AN TI NS ELACE S�c�1 \nTI N�_EV� D 5W-X C` RL C_ TA s agrees roinstall� dual Sewage Disposal System in accordance with the previsions of agrees not tap the system in opeation untila C"'ficale of Compliani e'hasbeen issued by the.Board of Health. C=Sign - Date Insp APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ------ --_.. . —_____ ---- _-- ——————————-- --—— THE COMMONWEALTH OF MASSACHUSETTS FEE /06 �A1J13L� BOARD OF HEALTH C RTIFICATE OF COMPLIANCE Description of Work: Individual Component(s) Complete System �` � 1 4 The undersigned hereby certify that the Sewage Disposal System,Constructed( ),Repaired( ), pgraded(1�Abandoned( ) by: MIYCSWL"L• NtY g at has been installed in accordance with thbQ��v_isions of 310-C 1 (Title 5) and the approved desi plafis/as-built plans relating twApplication N - J mated L � J Approved Design Flowy'1 (gpd) Installer _ - Designer: EAP, It� �r,RY EKE Inspector � Date T /��� / The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED ORM 5/96 jNo. 02 �/ ATHE COMMONWEALTH OF MASSACHUSETTS FEE CQ f3ARMSTz aLF_ BOARD OF HEALTH I SPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herety r nted o Construct Repair ( ) Upgrade '( V(Abandon ( ) an individual sewage disposal system at --. as described in the application for Disposal System Constriction Permit No. ,dated ��� Provided: Construction sha be co/plet�eyd within three years ofthe date of this pe�ill loc conditions ust be met. Date \ �S/ � / e- Board of Health FORM 2- DSCP DEP APPROVED FORM 3/96 ), FORM 12S5 (REV>!/98) HOBBSA WARRENTM PUBLISHERS-BOSTON i.' i r e Town of Barnstable •. ISM Regulatory Services Richard V. Scali,Interim Director BARNWABLE, 9� MASS. Public Health Division 039. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Sewage Permit# "I Assessors Map\Parcel Designer: I&A L LAN 7 f_'M P L Installer: ithoa� &i)ep y\�j � p�W� Address: I S �2TI A Address: S C 'u� QU � On >�'►C�� �511~►� Cpfv- was issued a permit to install a (date) (installer) septic system at 9 \ PH Eki NEVI S IJ\T based on a design drawn by (address) L A R L 1A1S)PCEN dated (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. certify that he system referenced above was con ct&Fin compliance with the terms of the IAA roval letters (if applicable) g HARRY -T EARL v LANTERY, JR. v ( . t e ature ,� .p.115 No.26575�p �. FSS�orJAt ECG (Des s Si ure) (Affix'Designer's Stamp Here) PLEASE RETURN TO RNSTABLE 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 t TOWN OF BARNSTABLE LOCATION �� .®1Y/rv�y`� N SEWAGE# VILLAGE C e-0�5re'�J'VZZZ"ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. ITJ 1 d60—`—a of SEPTIC TANK CAPACITY LEACHING FACILITY:(type) -0-4-C V (size) /3 C;r s`j1 NO.OF BEDROOMS OWNER (7 C3 Ze-o PERMIT DATE: COMPLIANCE DATE: /o e Z2 Separation Distance Between the: /Z, 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 Of any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY RtAR / 3 � 6r,41. sr 1 -.10 -C> 0 ( dT ® ra No. / Y Fee J THE COMMONWEALTH OF MASSACHUSETTS Entered in wrnpu er: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 3pplitation for Misposal �6pstrm Construction Vermit Application for a Permit to Construct( ) Repair(A<Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No.o;2 9/ Owner's Name,Address,and Tel.No. GCS>v�-I' �r G)lets Assessor's Map/Parcel 07 Jr® — �o Installer's Name,Address,and Tel.No. 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 4 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �. gpd Design flow provided -30'40 gpd Plan Date ®`''9 Number of sheets Revision Date Title Size of Septic TankJle-l-e- 11-l!' 6;4,e 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 o Health. S e ® Date lool� O Application Approved by ® Date Application Disapproved by Date for the following reasons P' Permit No. '� Date Issued „ No. r f Fee dk THE COMMONWEALTH OF MASSACHUSETTS Entered incompuer: !, Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for ]Disposal *pstrm (Construction Permit Application for a Permit to Construct( ) Repair(LIUpgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 9/ rs�ill//�/j' �`r Lw Owner's Name,Address,and Tel.No. { Assessor's Map/Parcel o7,.j Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. j 9 7 s'' 07,27 Type of Building: i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building C/;'e-t No.of Persons Showers( ) Cafeteria( ) Other Fixtures "f ` Design Flow(min.required) O gpd Design flow provided .3siG gpd Plan Date ”i Number of sheets Revision Date Title Size of Septic Tank,&, ///o /Sad GEC Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) J, Date last inspected: f 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 `a Compliance has been issued by this Board of Health. S e ! .:r' !1� ® //p O --� Date Application Approved by (��� FLU 4 V �L- DateVp / - - Application Disapproved by f,. Date for.the following reasons Permit No. �l { Date Issued - _ _- - -- - - - --�,-------------- - - - - - - Th F COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(� Repaired( ) Upgraded( ) Abandoned( )by c. ,O > zk&owd e,,&' �c f'ea-,Aye e at has been cons u ted in acc©rda►c with the provisions of Title 5 and the for Disposal System Construction Permit No dak L, Installer \7'�ytl � �oCT�U/� Designer 4!a4,60�/Q /JJ�jIJ'4�" !h'•�' #bedrooms (( Approved d s g flow .3�0,G= 1 n,� gpd The issuance of this penhi sh 1 not be construed as a guarantee that the system w functio -as designed. Inspector �Date / ' ---------------------- No. , 03 �01'/- V Fee \ rT HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS OispoBal 6pstem Construction Permit Permission is hereby granted to Construct(, Repair( ) Upgrade( ) Abandon( ) System located at ®��� G�A�/�*'�' ✓' y C A 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:Construction/must be/completed within three years of the date of this permit. / b ' Date' J Approved by i C;� 9b _ oc0 No.... -k Fa$..... .. THE COMMONWEALTH*OF MASSACHUSETTS BOARD OF HEALTH ......... .......oF��-+F - V�- ' o - Appliratiun for Disposal Works Tonstrnrtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (,- . Individual Sewage Disposal System at: �..�..�:...........................�..� 1.-:. �....... ......... ..........c��w��2�,�\��............................. % �►+ Location.Address or Lot No. er Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building .............. No. of ersons...._....................... Showers — Other—Type g -•---••-•----- P ( ) Cafeteria ( ) d Other fixtures ..._..... WW Design Flow_._.._. ...................gallons per person per day. Total daily flow.__.77a.:�� ..................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....../..O. ..... Depth below inlet......4.or....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) • . •-' Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to,ground water........................ 0 x ...............--........ Description of Soil....................................................................................---------------------------------------..............----•-•--............•--.--•-- V .-----------------------•-•----.........._....••......-------••-----------•-----•-••--•......-••-•-......------ --•-•----•-••-------------••--•...-•------...----•-............ ------...--•-----•- 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:ITL is 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by he bearof health. Signed. C. . ---- Date Application Approved By.............. -- = . ............. Date Application Disapproved for the following reasons--------------------------•------•---------------------------....----------------•-----------------------•••-•--- ---•-•--...---•--•--•----•---•---------------------------------------•----...---...--------•---._.........----••---------•-------•---------------------------------•-----------•-•---...•---...---------- Date PermitNo.------ . 4..- ................ Issued....................................................... Date i Town of Barnstable �IKME , Regulatory Services ti P °T Thomas F. Geiler, Director Ba ASS. �. Mass. ' Public Health Division y M $, Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508 862- 644 Fax: 5 8-790-6304 Date: 10 Sewage Permit# Assessor's Map/Parcel Im (0 Installer &Designer Certification Form Designer: c �, � Installer: Address: �I � � � Address: �� On -A l L WM. M was issued a permit to install a (da ��,'inlstaller) septic system at I �44 based on a design drawn by ,fin (addre s) ( I U dated (designer) �ertify 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 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 P� '-fions. Plan revision or certified as-built by designer to follow. Stripout (if r,- _.cted and the soils were found satisfactory. �-� OF MqS\ DAVID B. nstaller's Signature) MASON n1;F 9 No.1066 Olc;it Aj 1 /ST esi5 er s Signature) ) q r � \ PLEASE RETURN TO BARNSTABLE PUBL._ �� J �fE OF COMPLIANCE WILL NOT BE ISSUED UN i iL isv i ri i riv) r uRiNI AND AS- BUILT CARD ARE RECEIVED BY THE BARiNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAothce forms\designerceititication fonn.doc 'own of Barnstable P Department of Regulatory Services AHD 'Public Health Division G Date ,A stig9 w� 200 Main Street,Hyannis MA 02601 Date Scheduled — 0 Time Fee Pd._ Soil Suitability ,A.sse,s.s e't for SeOage Disposal S4,Performed By: t Witnessed By: 'es LOCATION & GENERAL]1VI+ORMA?IION Location Address Owner's Name C e �-e rut/l l e Address Assessor's Map/Parcel; 0 -•(� Q 3 I Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(46) Surface Stones Distances from: Open Walser Body ft Possible Wet Area ft Drinking Water Well Drainage Way ft Property Line ft Other ft SIMI TCH.'(Street name,dimensions of lot,exact locations of lest holes&perc tests,locale wetlands to proxindly to holes) I Parent material(geologic) Depth to Bedrock $ r Depth to Groundwater- StandingWater in Hole: Weeping from Pit Free Estimated Seasonal High Groundwater DE'I'ERMIPdAUON FOR SEASONAL HIGH WAI'ER'I'ADL ,' Method Used: t I Depth Observed standing in obs.hole: In. Depth to soil mottles: �.1 Dcpth to weeping from side of obs.hole: In, Groundwater Adjuslinent ft. Index Well# Reading Date: Index Well level_ Add.factor,.,,,,____ Adj.groundwater Level mm PEIICOL�ATION TEST Utite� Thne_ Observation Hole# ( '['rote at rJ" Depth of PereA Thne at 6" Start Pre-soak Time @Tima(9" 6") End Pre-soak Rate Min./Ioch Site Suitability AssessmetSite Falled: Additional Testing Needed(Y/N) Original: Public Health Division Olservtltion Hole Data'TO Be Completed on Back----------- ***1f 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:\5 EPT[C�Pf!RC�ORM.I?OC DEEP-OBSERVATION HOLI;LOG .Mole#�� Depth from Soil Horizon Soil Texture Soil Color Soil. Other Surface(in-) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsistencv,%Gravel) �1t5 o DEEP OBSERVATION HOLE, LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % ravel DJEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in_)_ (USDA) - (Munsell) Mottling (Structure,Stones,Boulders. Consistency,Iry Oraycn DEEP OBSERVATION HOLE LOG: Me#1 Depth from Soil Horizon Soil Texture Soil Color soil , Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consiatq-nm 16 QrpY01 Flood Insurance hate Map: Above 500 year flood boundary No_ Yes l Within 500 year boundary No" es Within 100 year flood boundary No-. Yes Depth of Naturau Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all Etreas observed throughout the area proposed for the soil absorption system? If not,what is the depthWhay occurring per 1 us material? Certification I certify that on Qdate)I have passed the soil evaluator examination approved by the Department of Envir ection and that the above analysis was performed b me consistent with . the required training,expertise and a ri ncc described in�10 CMR 15.017. � Signa -e Date Q:\SEPTlC\PF_RCFORM.DOC.DOC C;� 9b _ oc0 No.... -k Fa$..... .. THE COMMONWEALTH*OF MASSACHUSETTS BOARD OF HEALTH ......... .......oF��-+F - V�- ' o - Appliratiun for Disposal Works Tonstrnrtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (,- . Individual Sewage Disposal System at: �..�..�:...........................�..� 1.-:. �....... ......... ..........c��w��2�,�\��............................. % �►+ Location.Address or Lot No. er Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building .............. No. of ersons...._....................... Showers — Other—Type g -•---••-•----- P ( ) Cafeteria ( ) d Other fixtures ..._..... WW Design Flow_._.._. ...................gallons per person per day. Total daily flow.__.77a.:�� ..................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....../..O. ..... Depth below inlet......4.or....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) • . •-' Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to,ground water........................ 0 x ...............--........ Description of Soil....................................................................................---------------------------------------..............----•-•--............•--.--•-- V .-----------------------•-•----.........._....••......-------••-----------•-----•-••--•......-••-•-......------ --•-•----•-••-------------••--•...-•------...----•-............ ------...--•-----•- 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:ITL is 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by he bearof health. Signed. C. . ---- Date Application Approved By.............. -- = . ............. Date Application Disapproved for the following reasons--------------------------•------•---------------------------....----------------•-----------------------•••-•--- ---•-•--...---•--•--•----•---•---------------------------------------•----...---...--------•---._.........----••---------•-------•---------------------------------•-----------•-•---...•---...---------- Date PermitNo.------ . 4..- ................ Issued....................................................... Date No..... ......�a'. ... Fss..... 1_�... ......_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,� r �irtttilan�faar Binpnuttl Marks Tonntrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair Individual Sewage'Disposal System at: ...... -...Gt �..... ....................` . ._...�:;t tr_V:- -•-- - =-w'r c 2v,a. ?. ..................... ... Location-Address or Lot No. .............. =— =----- •`- ' .............................. ....................... . .................................. aOwner - Address .................... _••-•• •- ----------------- F.._� ! .......................................... � ..........................�:.Y.A!�► '�::v.�.--.----.................------------..._.. Installer .. Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms------__:�...............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures Design Flow.........., ...................gallons per person per day. Total daily flow.._._73�.�__.................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter..._......_..... Depth................ x Disposal Trench—No..................... Width.................... Total Length.__.._._..___...._ Total leaching area-____--_---_-----_sq. ft. 3 Seepage Pit No.......,(............ Diameter....../.n�..... Depth below inlet.....A_r....... Total leaching area__________________sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per Inch Depth of Test Pit.................... Depth to ground water........................ fsr Test Pit No. 2----------------minutes per inch Depth of Test Pit..............._---- Depth to ground water........................ a 0 Description of Soil...................................................... -•----------•-----.....-----------------•-----....-----.....---- W --•-•---•-------------------------------------•-••---------------•-----_-----.....-----.........-•------._.........----...------------.••------....----.-_... ---._............_...-----...... x -•---•--•--------------•-•---------------------•---------•---------------------------------------•-----•------•-•--------------------------•------------•------------------•--•---------•--•------------ U Nature of Repairs or Alterations—Answer when applicable----------ta-r_v.....o. ` --------&.?7''.�------ : _? `___... ............ '+' - '.... --t `= =-•----''' ,cam -= s-! " f S-- no ---, ---- --------- --------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 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 he board.of,health. Signed ------ -=---- - ----------------- }, f Date ApplicationApproved By.........................................................................._.....---------..._.... ........................................ Date Application Disapproved for the following reasons----------------•---------------•-----•--..........=............................................................ ...--•--------------------•--•-----•------........-----------.....-----......-----.............-----••---......---•--•--•--------------••----•-------•---------...-•---•----.....----....---......_--•--- V _ Date Permit No..------.e.--1- _/.ate --------------- Issued....................................................... Date -------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH +....OF1F ,!2.Jr,-.5� ?..�` .............. .... �rrtifirtttp of fanut�littnrr �. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (t ) by...................................... . .! F....L-t4 vt.Ij_Z_ -�-' P = .. ------------------------------------------------•--------••- Installer _ at.........--•-•............. .....�:: 1 .---•--- L L 1 u't1 *- ^f" ``- C ;1 _v':. ,c -------••--•.................... has been installed in accordance with the provisions of TI i L1 r of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------------ -�?- 1-� _ -- ------------�--�� dated- �-----------------------..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. n DATE........................? ..".. ......�.. ...........------------. Inspector---------------_- ........................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.. FEE.....r�.-tn...... Disposal Works Tnnntrttrtion rrntit � Permission is hereby granted......... - f" =---- to Construct ( ) or Repair ( t...)_an Individual Sewage Disposal System atNo..................... .`?.-t------... _ ...........................l. -C f i.'% - ----------------- ----••--...--.-- Y Street - as shown on the application for Disposal Works Construction Permit No,-�-y.3��Dated.......................................... ................................. ..................................................... DATE................... -`---- .............................. Board of health l 0 I 1 100. OD Ki= Mwr_ \T� jet F�F 5 x1 s a*i� LiZ. 5 /5 - 1 �. �iitn)�� -r7./1_':• d 11 i. 6 fi�fJ. �� �:,rX �OV�J1 R T r I �tj/yi'tJtl, ftoiZt EJ,L '�f.i .,. rC.5> i� t T .�! � 5-?T)C. r 9-(b an + - � Ro—raTL 9 b 4. -1(.� i g- �• a D --- ' ��_ �'� �O t3�.��c ! NOTES: C=L 1b16.WQ� 1. Disposal System to be constructed in strict accordance with Commonwealth of Mass. Environmental Code — Title V. 1 2. This Ian is for the sole r ;�r,_�� p purpose of construction of a septic system upgrade. 3. Contractor to call Dig-Safe 72 hours prior to beginning of excavation. 4. Contractor to field check outlet invert at existing septic tank. �Qp 5. Bench mark is elev. 100.0 to i p of foundation (assumed). 1CI0 .Do' � ,'1 6. APN is 239 / 010 / for Town of Barnstable. 11 - 1 7. Sub-division is served by Town water. r�! g � � � �-----�----•a �� 8. The plan view i i �- 4 al h\L� p s based on plan by Arthur Thompson, RLS recorded n �._\___._._________ J - 5, I plan book 121 / 125. Barnstable Reg. Deeds. m \\ ✓� ✓�nP' 9. Pump existing 1,500 gal. Septic Ta nk, check for Tees and gas ba ffle. Crush and remove existing S.A.S. `- 10. Use 2-5'x8'x2' P.C.L.C. w/ 4' of %" to 1 %" double washed stone. Y ; Cover with filter fabric per Title V and town regulations. Place a 40 mil. r 3 F3coRM _ barrier between the house and the S.A.S. as shown. .A I - , 1 11. Notify engineer at beginning of over dig. ' - 12. Grade, loam and seed all disturbed areas. - ! E P� OF MAS ! L UWl 1 WR 3 `5 Rv CP Z > 5.L Tn �_ U FL A E }SN No 265 p ti .! aNAL mp OF H t L 5C_/ F_ 3 = 2C1' UtGAt<15MIN. 300 Vti 1 U �lILLE Fri R.s h _ •, F�rZo+'n` +7t:r�>� h t\+ 1U SE_ ? g x I�i,LC �'- ''/u 1 %z c -' C "�• :� `�— c X i37.1 N C, f`f,,!.��nU i� I ` ,'. �',;. 1'�w f'T 14 2 . Z Ate- _ .; . .. -_ i JG AL5^ _ ASSESSORS MAP : 2�3C�.__ _- ----_____ TEST 1-IOLL LOGS \ PARCEL : /c) i FLOOD zoIJE:L _ I ro%__._._. -_— --- ------ SOIL EVALUATOR :: �1" `;Q C�j�. 1) 'Flie installation shall conii.,, with T'ille V :uid "1'owu of i+1�,l�uard of REFERENCE : ` - WITNESS : \ `� �` _ 47 DATE:____fLT I lealth Regulations. 2) The installer shall verify the location of u(ililies, sewer inverts and septic __ G�� . /Z /2��- PERCOLAT I cii RATE: C u4l�_I, , v� � y - - -- — ---- -- _ components prior to installation and setting base elevations. ...� 0 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. 7 he first TII- l TH-2 two Icet out of the d-box to the leaching shall be level. — 4) This plan is not to be utilized for property line deternrinakon nor any other ----- --_ -- - purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. � r f 6) Parking shall not be constructed over I I10 septic coniponeuts. LOCAT I ON MAP � -- 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt \ of payment for the plan and installation based on the plan shall be deemed ID ? /� approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per t p �, �j31 ' � p .C ._ Title V specs. 10)System components to be 101eet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCI1 40 PVC with ends grouted if applicable. T'he proposed SAS is being installed below the water service SEPT I C SYSTEM D E S I G N line. The line is to be sleeved as aforementioned and maintained in place. I 11) If a garbage grinder exists it is to be removed and is the responsibility of the FL071 ESTIMATE owner to ensure such. 12)7'he installer is to take caution in excavation around the gas line if such `� � BEDROOMS AT II0 GAL/DAY/BEDROOIA -50 GAL/DAY exists. 13)The installer shall verify the location, quantity and elevation of the sewer \ SEPTIC TANK ' lines exiting the dwelling prior to the installation. i 14)This plan is representative only that a system can lit on a property meeting -� GAL/DAY x 2 DAYS Title V requirements. USE I530C )GALLON SEPTIC TANK _SOIL ABSORPTION SYSTEM �,(M OF ID / _ O m _- -- - #d \� �L�j._ SIDE AREA: z�- + 13 `Xzx - - i sos �o \ BOTTOM AREA: ' ; 2 ��1ARIR / .�J ....r" SZ-P-T i C SYSTEM SECT I ON �- 0\ ----� �OF or- ► L 10 J, \ W X . 1. � �b� -- r, � �U-Box �6,� � '`�f I ! �� C. SAL ^I(��.� �11 2 � � a4�" ' ".7 =" '�, SEPTIC TANK v \ a � 7 - -- __ S I I-E ANv SEWAGE PLAN Via_1✓fit�__Ll ► ✓L__ + __ �.._ L0CAT 10N : -PH I�� 7 ��� PREPARED FOR : 5411- � p �1 --- �. M r DAV I D B , MA3011,R$ SCALE : I 1 0 DQC ENV I ROIJMENTAL DES I GHS DAlE : - — I_A5 r SANDWICH . MA DATE IIL"AL111 AGENt ( 508 ) 833- 2 177 U z a w 2