HomeMy WebLinkAbout0121 PINE STREET - Health 121 Pine Street'
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Town of Barnstable P# l
Department of Regulatory Services
s Public Health Division Date 0
03A ♦ 200 Main Street,Hyannis MA 02601 OA I ^
.
Date Scheduled 0Iva Time Fee Pd. o
So i uitability Assessment for SewageDisposal V 0/
Performed By: Witnessed By: 41,414 27,& P�/;�/)w
Lp. �
CATION& GENERAL INFORMATION
� t
Location Address �. n/'ArOer'sName
Address la I \^^"ice
Assessor's Map/Parcel: o� ( Q b(pO� Engineer's Name
NEW CONSTRUCTION^ REPAIR Telephone#
Land Use ` �� T1 is Slopes{9'0) L Surface Stones /
Distances from: Open Water Body ft ,Possible Wet Area ft Drinking Water Well �/ft
Drainage Way ft Property Llne- l C> R Other It
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
I
Parent material(geologic) �� w"�u�l Depth to Bedrock'
1.
Depth to Groundwater. Standing Water in Hole: U`� �'t. Weeping tYom Pit Fpee *_�
Estimated Seasonal High GroundwaterrN-i
DETERMINATION FOR SEASONAL HIGH WATER TABLE '
Method Used: '
Depth Observed standing in obs.hole: In. Depth t0 Sgll mottles: In,
Depth to weeping from side of obs.hole: In, Groundwater Adjustment I $.
Index Well# Reading Date: Index Well level Adj,factor,�.,r Adj,Groundwater LA fVal,,,m yy
PERCOLATION TES_T We Time
Observation
Hole# Time at 9"
Depth of Pere Tlme at 6"
Start Pre-soak Time C# 'T�li t 'lime(9"-61)
End Pre-soak
Rate MinJlnch
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:SEPTICU'ERCFORM.DOC
I
DEEROBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
o iste vel
�✓ L� l 6 7
t Z,1-5 ` S
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,
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
i to
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
0
s_
t Flood Insurance Rate May: /
Above 500 year flood boundary No— Yes
Within 500 year boundary No ,!�/Yes
Within 100 year flood boundary No '! Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious in tonal exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what,is the depth of naturally occurring pe vious material? ... ,_
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Enviro mental Protection and that the above analysis was performed by me consistent with .
the required training,expertise an, exper'en a described in 310 CMR 15.017.
Signature
Q:\.SEp1n0PERCFORM.DOC
e�.
TOWN OF BARNSTABLE
LOCATION j' 1 `►;ae,$t SEWAGE#
VILLAGE (%J i I e ASSESSOR'S MAP&PARCEL a 8�(®�,•�
INSTALLERS NAME&PHONE NO. S c c From it
SEPTIC TANK CAPACITY if&15--1\J (Q (A C-1 10 cs).
LEACHING FACILITY:(type) 3 0 h (size)/,2,$- X 30
NO.OF BEDROOMS
OWNER G(�S We.1l
PERMIT DATE: COMPLIANCE DATE: / /1 D
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 / �� t' �1' .
_ 30�® It(eAt-o rs
No. . D Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pphratton for 3h5pont 6pgtem Con0truction Vermit
Application for a Permit to Construct O Repair(-Upgrade( ) Abandon( ) ❑.Complete System❑Individual Components
Location Address or Lot! No. t a� \Q�j�Q S� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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(min.required gpd Design flow provided � gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil —Coe-'] Ste/•
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 of Health.
Signe +' Date 1 1-/ tO
Application Approved by Date!
Application Disapproved I Date
for the following reasons
Permit No. Date Issued
4te�
�! S ,�,.
i No. ,# Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
- Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for D(gpogal 6pgtem Cottgtruction Perron
Application for a Permit to Construct O Repair(►,Upgrade O Abandon O ❑.Complete System ❑Individual Components 3,
I �
Location Address or Lot No. �a Q S Owner's Name,Address;and Tel.No. I
L��csv \\ �. w{�`�
Assessor's Map/Parcel0-0
�- �rGs
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
M�bO ^
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(min.required)3��� gpd Design flow provided \? G
1 gpd
Plan Date 1 19 �00� Number of sheets Revision Date
Title
Size of Septic Tank 6X k zi \00 U Type of S.A.S.
I
a
Description,o,f Soil — [ e j Sr", J-
Nature of Repairs or Alterations(Answer when applicable) A8 J �
Date last inspected:
''Agreement: f
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 of Health.
~ Si e w ate ,1,- t0
Application Approved by Date/ [�
Application Disapproved by: Date
f for the following reasons
i
Permit No. Date Issued
----------------�---------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance,
4 THIS IS TO CERTIFY,that the On-site Sewage Disposal Sy,$a on2 c e/ (i� /� Repaired (✓) Upgraded ( )
Abandoned( )by c7 C�}P_ cc'eus 4•r t�`� J
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer QL.�P_ M y S U
#bedrooms Approved design flow gpd
The issuance of this pe t shall)hof _ onstrued as a guarantee that the system i'rfu tion as designed
Date Inspector
----- ------
----•------ ---------- ----------
No. Fee
O/
r
E COMMONWEALTH OF MASSACHUSETTS ' `
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
ligogal *pgtem Cngtruction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
i Provided: Constructi n must ;e co leted within three years of the date of this
Date �/_�oz Approved by P's
i
Town of Barnstable
10 Regulatory Services
Thomas F.Geiler,Director
+ IAItN.S'�'t4BLE. s
a Public Health Division
�. 639. `0�
'°TFnMa a Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
i Installer &Designer Certification Form
Date: �`h�-1 'TE)
Designer Installe •
Address: . �1 �� ���G�-� Address:
w,
01 l, 1 Z���
wa issued a perrrz:to install
(da e) (installer)
septic system at 2-1 6ME1i ye4TAILL-Gased on a design drawn by
(ad ss)
't �/ ►''I�lc� �,� datedIN
(designer)
Iv:certify that the septic system referenced above was installed substantiallyy according to
,16 design, which may include minor approved changes such as latera relocatiaxi of the
distribution box and/or septic tank.
x;
I certify;that the septic system referenced above was installed with`'.maj'or changes
greater than`l 0' lateral relocation of the SAS or any vertical relocation of any component
of the.septi�=system)but in accordance with State&L6cal,-Reg nations. Plan revision or
certified as-built'iy designer t6 follow.
f.
' `(Installer's Signature) : B.
NIASON rn
No...t-066
SgNITAR�P�
(D er s Signature) (Affix gner's Stamp Here)
PLEASE RE7CURN TO BARNS ST"A9,t PUBLIC:-HEALTH.DIVISION. CERTMC TE
OF: CQWL- IAN.CE WH L,-.�N®T lE -- SSUED,�I�I�t._M`BOTHr'THIS IF w-, ' AND AS
BUILT CARD ARE RECEIVED B'Y THE:BAR. STALE PUBLIC IDEA�,Tt DIVISIOI�I
THANK YOU.
Q:Healtii/Septic/Designer Certification Fonz
ASSESSORS MAP: Z , TEST HOLE LOGS
NOTES:
PARCEL :
FLOOD ZONE: SOIL EVALUATOR:
t
WITNESS : 1ALO a, VL(It? -� 1) The installation shall comply with Title V and Town of Barnstable Board of
REFERENCE: G �7? l +Q PZ-07 ,�L�/ " ^ DATE. S�- Health Regulations.
�XT Q, l,y }� t xtX �e4 PERCOLATION RATE: �- � ► l + 2) The installer shall verify the location of utilities, sewer inverts and septic
components prior to installation and setting base elevations.
3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
1
TH- ! TH-2 two feet out of the d-box to the leaching shall be level.
Lta'3t 6 ,l� / 4) This plan is not to be utilized for property line determination nor any other
��/ ! ��� $,d 1 '✓6L purpose other than the proposed system installation.
Lt" tn-e .1 � .�10 5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H10 septic components.
LOCAT I ON MAP�tJ T6 61 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
I
+ 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 washed
t � (l� 6��0 1 �(j�,� „ _ sand per Title V specs.
�- 10)System components to be 10 feet from N\ater line. Sewer lines crossing the
.__ ._,._- _ water line shall be sleeved with 4 inct, cru n �� - ;f
_ _ 10 , N with end. -rcu,cu i
.� �T ES I GN applicable.
11) If a garbage grinder exists it is to be removed and is the responsibility of the
FLOW ESTIMATE owner to ensure such.
12)The installer is to take caution in excavation around the gas line.
fj _ 13)The installer shall verify the location quantity and elevation of the sewer
BEDROOMS AT GAL/DAY/BEDROOM! 3 �AL/DAY
lines exiting the dwelling prior to the installation.
SEPTIC TANK
1
1 i
(11.L/DAY x 2 DAYS - � -C>GAL
I USE /6'�- , GALLON SEPTIC TANK
ie �� SOIL A?SORPTION SYSTEM
5 /
H jL -2-
. .s.
1
S I DE AREA: 2- �73'
BOTTOM AREA: -2� 33 n I 7-:5
� Z
SEPTIC SYSTEM SECT I QNo-k. -)
ly
+ `-- SOP o t= �_u��ito���.-� � *�.� � --•.�
. 4 -
I b GAL ,�j - sill
I ° b
SEPTIC TANK
ID
!\�2--7-L
41'n-L41
ICL
-D LW,yfl wW `SStx
J11
16
�4 S 1 T E AND SEWAGE PLAN
FCATION :
�.. .
PREPARED FOR • Gbo �LJ --
ch<b`T;
SCALE:o
11�lSPEC`f1PO _ _ �� '
DAV I D B . MASON 05 DATE: Z
o
DBC ENVIRONMENTAL DESIGNS /
EAST SANDWICH . MA
3 DATE HEALTH AGENT ( 508 ) 833— 2177
w _
Z
Y
TOWN OF BARNSTABLE
LOCATION / , SEWAGE #
a7i-
VILLAGE ASSESSOR'S MAP & LOT �pf
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY Et:0
LEACHING FACILITY:(type) &,o �� (size)
NO. OF BEDROOMS y PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER R?R o
DATE PERMIT ISSUED:
LATE C011PLIANCE ISSUED:
ARIANCE GRANTED: Yes No
J
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1,140 ............ � Fps............................_
THE COM/AM�ONNWEALTH OF MMASSACHUSETTS
BORD
fH; q)H
...................................OF............. ✓......�
21 ApplirFataun for 11hipas al arks Toustrurtiun Vamit
Application is hereby made a Permit to C nstruc ) or Repair ( ) an Individual Sewage Disposal
System at: / �� � �. - ✓�,/lJ�%1 ✓ r'
............ ........................ . --.----•-••-•-----.----- - ••--••••••. -
��' on- dr r t. 1 _ ..... ---. �---- .. j....�...:5 -----------................. ...... .....
------.-.-
r w ` .....
1�Idi J
n J _ I i/Ac]�ir ss
a ...................yJ ..._ ----.--------............................. ......`! _ ...... .....................................Z�
Installer Address
UType of Building Size Lot.....710 . .Sq. feet
Dwelling—No. of Bedrooms...........3............................Expansion Attic ( ' ) Garbage Grinder ( )
Other—Type T e of Building No. of persons........................ Showers
Ga YP g --------•----•-•---•----•--• P ---- ( ) — Cafeteria ( )
Q' Other fi tures ....................... . .
W Design Flow:........._ _ ...........j�allons per person per day. Total daily flow__._....-3. ....................gallons.
04 Septic Tank—Liquid'capacit� ._ allons Length...... Width.1.......... Diameter________________ Depth................
W Disposal Trench—Np.....-----__-_----- Width__.......... . Total Length.................... Total leaching area....................sq. ft.
�Vl3 Seepage Pit No..._.._�._.--_____-- Diameter..... ............ Depth below inlet............... Total leaching area_.t2J..._sq. ft..
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,-a Test Pit No. 1...... .minutes per inch Depth of Test Pit____________________ Depth to ground water........................
(Z Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
� - ------- --------_---_- --_ ---•••-• . .....-
Description of Soil.....00...... ------•---- ......... 2; ------.�-----------•-------- ...
---.. ...
W
UNature 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 TILT f E 5 of the State Sanitary Code—/JFhe un signeq1tirther agrees not to place the yste in
operation un Ce ificate o C has bee iss by h rd ealth. /
ed--- ----•-------`.................1/.------------..... s 7 D
D
Applicationproved By--- ----.. -1 -- .. ........................................................... L �
Date
Application Disapprove or t following reasons----------------------------------------------------- --•--------------------------------------------........._
.........-•---•-----•..............•----......----•------------------•----•-•-----------.......------------••----•-••--•------------------------------•--•-------------------------------•--•--....-•---
Date
PermitNo......................................................... Issued.......................................................
y
"No.f1...J...22/.� Fim...............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR0�_
® A .
....... ......OF........................................... ----•--••---•-............................
AvIlfirFa#ion for Disposal Work Tnntrurtiun Prrmit
Application is hereby made r a Permit to Construct l ) or Repair ( ) an Individual Sewage Disposal
System at:
fion- dd ,/ f f
A
:..._.
A11d'S
Installer Address -
dType of Building �* Size Lot......:.:.. ...............Sq. feet
V Dwelling—No. of Bedrooms_........_3............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building ....... No. of persons.................•..._..__.. Showers — Cafeteria
a YP g P ( ) ( )
a Other Mures -----•-••--•......---•--•-•-•-
WDesign Flow........... .: .......................gallons per person pe day. Total daily flow.......32_1_!;�.....................gallons.
WSeptic Tank—LiquiTd capacitGallons Length..... ..... Width__:........... Diameter________________ Depth................
x Disposal Trench—No...................... Widt .................... Total Length.................... Total leaching area..___......._.......sq. ft.
.
3 Seepage Pit No....../........... Diameter.... . ......... Depth below inlet...............Total leaching area.`-�z_. sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1......:Z7::�_.minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2..............:.minutes per inch Depth of Test Pit.................... Depth to ground water........................
•............ -------------- --- •-.-•--•- -. r -----
O Description of Soil....6 ... -•----•--._ �' -- t. . t6��------.- .'�� ...-• .....----"-..........'----
x --------------------------------------------
-...........
-----------------
---------
----------
.------------------------------
•---------------------•---------------------------------------------
W ••••------•••----•------•----------••---••--•-•••••-•--•••----•-••••-•-•••--•--•--•-•-•----••-••--••--••--••••-----•---••--•----•••--••....--•-•••--•-••-••--••••-•--•-•---••••.............•--•.----•-
UNature 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 IT
p 5 of the State Sanitary Code. The u e; signe .furtl er agrees not to place the syste in
operation u > C ificat C. e has bee iss d b t oard ihealth.
pl/--cethe
ned. . ............. ........................................ ................... ...... -•_D.. ..
Application roved B ...... �_w ...................••-------.....------•---.............-- --.. _ ._ ..3......---
PP PP Y
Date
Application Disapprove or a.following reasons:.................................................. ...........................................................
--•........--•--••...•••---........-•••••-••-•--••--•-••••-•-•-----••-•••-•-•-•••-••-•-•-••••••••--••--••-•--•-•....-•-•••••••-••••---•••--•--••-••--•--------•--•-•--•-•------•--•--•......-••-•....._
Date
PermitNo......................................................... Issued_.......................................................
Date
HE COMMONWEALTH OF MASSACHUSETTS
BOARD�JFF HEA TF
...............................OF......................................................................................
TrrfifiraV of ToutpfiFanrr
THIS IS TOn1174�,
That the I : idua Se age Disposal System constructed ( or Repairedby.............. ......._. ....._.. ....___._................_._....._............ ......_
l _ f Installer '
at-••-••••••-••••-••••-••---••--•••••••••........----•-......•..............••••�-..'-_••- ....:-�:"�'. �-'`�......---------------------- ---
has been installed in accordance with the provisions of TIT�Y' ) O�je State Sanitary �de s d s din the
application for Disposal Works Construction Permit No......i... ....- .....�__-•-__. dated_ .___ -
application ISS ANCE OF THIS CERTIFICATE SHALT. NOT-BE CONSTRUED AS A ARA EE THAT THE
SYSTEM )NIZIL� NCTION SATISFACTORY. 1R
DATE....- •- •-•- •••----••........................................................ Inspector_...-- . -----•--••--••-••---•-------•-----••-•••........................._._..
E COMMONWEALTH OF MASSACHUSETTS
BOAR F HEA -T / rL✓
A �.. ........OF....:.................. 0
p..............................
NoG..Z... - �.. `e FEE..:..:..:...............
� rrntt�
Permission is reby granted ......................
to Construe (t or Repair ( ) Individual•S gage Disspo S stem
at No... !.............. .... :--`=9--- f' _ " . `.... ......... ..�. _........ .............
V .
Street !r
as shown on the application for Disposal Works Construction Permit No._ �-._ ✓, j '�
ted . ----- --•--......
...................s'' . ---------- .......-----'=
Board of Health
—� ��
DATE...............................••-•••-••••...............-•••••......-----_....
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - -
;i GAL FAMtt_Y - -3 BEORooM .
1.1L; .6ARBAC�G j;�LtNDE2 100.
ov E}(a
I .� O ;
!I U!a►L � F�oW _ 110 A 3 = 33oG.P M
5EPT1G TArJK = 33Oxl5o% �95G.P.
y5t= 100o GAL-. �f1 0- ` •{.(.
P v5E 1000 6At_.
I �15Po5AL 1"1" ,•:, ����•
S Dcv/ALt_ AeGt - I�o s,� 4P•3
50T TOM AREA-
50 S.F• X 1 0
--T oT A 1-- O 6.S 1 GN 42 5
-T oTAL hA I t-Y FLOW
j PE2COLATtou RATE : I''tN ZMiN 9
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