HomeMy WebLinkAbout0116 ANSEL HOWLAND ROAD - Health 116 ANSEL HOWLAND DR., CENTERVILLE
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UPC 12534
No. 2-153LOR
MASTINGS. MN
No. < —7 6 - Fee $50
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNS TABLE., MASSACHUSETTS
2pprication for -Mtgp0al *pztem Construction Permit
Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
116 Ansel Howland. Rd.. , CentervillE John Mara
Assessor's Map/Parcel 12
_ Z
Installer's Name,Address,and Tel.No. t� Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 4 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 Sand
Nature of Repairs or Alterations(Answer when applicable) 'T e-5 leach system, consisting
f
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by t '�B � Hea . J Q9
Signed Date J /
Application Approved by DateZ—
Application Disapproved for the following reason
Permit No. — 6 Date Issued 1 (Z�
No. '/ / / 4 Fee 1 50
THE COMMOMALTH OF MASSACHUSETTS Entered in computer:
�-76� PUBLIC'HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes
„.-
application for Mi5paaf 6potem Con0tructto trout
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
116 Ansel Howland Rd.. , Centerville John Mara
Assessor's Map/Parcel I-� ( _ .Z & V
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P 0 Box 1089, Centerville
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"
il" Sand
' 4��7 1
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system, consisting
of a D-box and. chambers wi s onp all ar0r7 .
Date last inspected: `.
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in`accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued etB d of Heal b a..r l� Q
Signed _.wry" " Date /
Application Approved by C 11 IA 2Z70 - Date
Application Disapproved for the following reason
Permit No. - 6 Date Issued
--------- ------------------------- -V e
THE COMMONWEALTH OF MASSACHUSETTS
Mara BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )
Abandon id( )by Wm. E. Robinson Septic Service
at 1�6 Ansel HowlandRd. , Centerville has been constructed in accordAnce
with the provisions of Title 5 and the for Disposal System Construction Permit No. q /CO/ dated
Installer Wm. E . Rob ins on S r. Designer
f f P
The issuance of this permit shall of qbg cons u d as a guarantee that the syste. will function as designed:f rr` 1/)
Date Inspector I A An f
V
--------------------------------------=
_ 41-0_�.
No. ! ,t `Fee
71- Z( O THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS 4
Mara ,
MiOpogar *pOtem Con5truction Permit
Permission is hereby frbantV to Cgnsgt(, )�epa d(� X)�ant ervilledon
System located at 1 nsel tiowlan o
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. L)
Provided:Construction must be com leted within three years of the date of this Dermit. l
Q
Date: �� / Approved by ,�.� / ,/,�-/�...1
f
+� 116199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERNIIT (WITHOUT DESIGNED PLANS)
Y William E . Robinson,S,rhereby certify that the application for disposal works
construction permit signed by me dated �I l ^ g concerning the
property located at 116 Ansel Howland R d C Pnt Pr.r; I I meets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the'proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
L
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation +the MAX. High G.W. Adjustment
DIFFERENCE BETWEEN A and B
9� v
SIGNED : DATE; ;
[Sketch proposed plan of system on back]. TT��
q:health folder:cert
a
TOWN OF BARNSTABLE
LOCATION _I l R wS F ( ow(w�u 9 b CL UL SEWAGE # 9 —
I
VILLAGE ��c►^%�Nc2y� �(( ASSESSOR'S MAP & LOT 0
INSTALLER'S NAME&PHONE NO. 1�!`1 C— %BSc�J SrPfIC Z ZS��C�Z�
SEPTIC TANK CAPACITY 1 E y o 0
LEACHING FACILITY: (type) 3 i2.1 t,j C— (size) 12 X 3 0 Z—
NO. OF BEDROOMS LI
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: t l_I l k q
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
0 �
Ir
1 �
Q �
N") Mn S d 1
L
L0CATID 5EINA E PERMIT NO.
VILLAGE'
I N S T A LLER'S NAME i ADDRESS
�126 3 l A O Cl /L
YTIRV ERR fU MM ,070
SU1LDER OR OWNER
7 x u",3DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
3
5
TOWN OF BARINSTABLE
LOCATION &LA1A0J D ])QL V(-- SEWAGE # 9
kLLAGE �c►N�N(2V( II(r ASSESSOR'S MAP &LOT v
INSTALLER'S NAME&PHONE NO. OM. C 2,0'OIrJSW SEpKC- I IS R 17L
SEPTIC TANK CAPACITY 1 v o O
LEACHING FACELIT`Y: (type) '� 0 tR�l W C L S (size)
NO. OF BEDROOMS 14
BUILDER OR OWNER
PERMIT.DATE: ! COMPLIANCE DATE:
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 j
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
�ouSC-
4c 16
t PO 5vw 900("�
t
i
1
FEB
THE COMMONWEALTH OF MASSACHUSETTS l
BOAR® W H T
'12...........OF..... .........� ..............................................
ApplirFation for BispaaFal Works Tnntitrnrtiun tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sstem a .`� ---......... !� ,.; �� _.,� ...........................................
Wa
L!o1:ca An ; s
� —o o.
/ ._._._. ..._ .........-----............._._...........---...._...
OwnerT-------------------------------- _ Address
. - . --......---•------•-•----------------------- ...---
------- -----=�'�c��.•. .....------•-•--.....------•_-------•---•-----••---......
Installer Address
Type of Building Size Lot__l jr.�� ` _._._Sq. feet
�., oms._.�• ________________________________Expansion Attic ( ) Garbage Grinder
Dwelling—No. of Bedro ( �)
�`k Other—Type T e of Building _______________ No. of ersons_______._________...__._.___ Showers
yP g ------------- P ( ) — Cafeteria ( )
Otherfixtures ...........................................................••-•-••---•---••••-------•••-•••••••-•-••••••......•••._.._...---•-••-••-•--••--•-•--•----
Design Flow______ _. _ gallons per person per day. Total daily flow..... -_ .................gallons.
WSeptic Tank—Liquid capacity/�.-04�gallons Length................ Width................ Diameter................ Depth...._...........
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.__Y-_ ----- Diameter........... Depth below inlet____________________ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,.� 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........................
-----------------------------------•-----•------..._..-•-------......-•-•----•--....---•--.......---.........................................................
ODescription of Soil........................................................................................................................................................................
x
U •••••••-•---•••--•--•--••-•-----•-•••-•._...---•••---•----•---•------•---•---••••••••--------------••-••••••••--•--•-•---------••-•••••-------••-•••-------••--••••••-•-•-......-•••----••••------------
W
x •-••--•.............................•-•••--•---------------•------•--•----------• •••__...•----••-•----••••••-••-•---•---•-•••-•••••--••-----••••-•••-----••--•••••••--•••••••-••-•--•••-•----.......---
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 TLITi I:;�. 5 of the State Sanitary Code—The undersigned Jurther agrees not to place the system in
operation until a Certificate of Compliance has been issue by the board o iealth. / may,
Signed � ��.. �-..•----------••.... �" = 7r
~'g` y ate
/v
ApplicationApproved By....... �� ----------------------•-------- -------•-•----------Da -----•--------
Date
Application Disapproved for the following reasons-......................-.........................................................................................
..................•--•-----••-...-- -------••--•-•-•-•--•------•--•••....•----•-----••----•-•--•-•---
Date
PermitNo......................................................... Issued.......................................................
Date
:r
..�:f... ._
«. THE COMMONWEALTH OF MASSACHUSETTS Fps..
BOARD OF HEALTH
............. ................OF..........................................................................................
Appliration for Mipooal Workii Tunstxnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................-................................................................................ ..-•-••-------------------................---• - - .....-----
Location-Address or Lot No.
......................__-....................................................................... --....................--------•--•----.....----•-•--•.........-----•..............................
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures ----------------_-_-- ............................
W Design Flow............................................gallons per person per day. Total daily flow............................................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.................... Depth below inlet.................... 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..................T,__.
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
p+' ......................... --------.----------------------..........---•-------------•---.._.............----•-•...._..................----------••-----------
ODescription of Soil........................................................................................................................................................................
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 TITS:,-. 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
Application Approved By.......... ___..
-�-��...�---n.--,�.---�- ate: ----------------•--------- -------------------- -------------------
Date
Application Disapproved for the following reasons:.............................................................
..........................•. ----•----.....
-----------------------------•---------------------------------------------------•-----------------------•-----•.....-------•--------------•-------------------------------•--------------------•-------
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............: 01:w: .........O F........ ,:Y1;. ..................................................
(9rrtifiratr of Tomplianrr
THIS I'Y
O CERTIFY, That the Individual Sewage Disposal System constructed ( �or Repaired ( )
a
by---•-------------- ov.&.
Installer
;1
at D?r ,.. s 11_.f _ --------------4"_...Y.t.. . _, '........
has been installed in accordance with the provisions of TI T L 5 of The State Sanitary Code as described in the
.. I
application for Disposal.Works.Construction Permit No.---...t. 4! ....... da ed--..............................................
THE ISSUA VNI
THIS CERTIFICATE SHALL NOT BE CONSTRU S A UARANTEE THAT THE
SYSTEM W SATISFACTORY.
----•--••--•--------------•--•----•--...... Inspector---•-------------... ..�. -� -----...................................................
.: THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................
No..................... FEE�,r............
OWpasat Vorkii Taonitrnrtion amit
Permission is hereby .granted. ......>D�:.�------•----------------------------------------------------------------------------------------
ct to Constr oL. Z air ( ) a ndividu Sewa ispos l Sy�tem
Street
r as shown on the application for Disposal Works Construction Permit No..................... Dated...........................
----------------------•-•-....---.....--
Board of Health
DATE....................... (• ..........................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Y..
t►�G�c-. F A M 1 L�( - 3 B�O tzo o lv� '� ~' � �,,, .. 1
WO GA¢P,AGir �jR.iiJDE2 IJS�L. r" �l�.IL�►JD
pA�LY Pi-Ow s I1O x 3 -4-
rjEPTLG TA►IJK = 330xl5t>% = -4956.P. Q
u 5E- l o 0 0 6A L...
015Po5AL P1T u5E IOoO GAL. r�
S�DG.WAt.L AP-SA. = t 5d S.F � M�71000
lG f
50TTOM AQEA= 50 5•F• 0 N
• N 1
"7 oT A 1-
'TOTAL- IAA t 1-Y FL-Ott.( = 330 GPO '3(p .T �v�IDAT/O t4 �
Pszcol-ATIDu RATE I"IN 2M M OV-LE
---__. -- cap
kkkA0. X°R 0—
a hi''t P'r �40
OAXTER
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Na 2•:^,•ia (�, I nor.,
St -Top F>JD'=�,Z
hoz
I
d9 ,
.� � � r•ten �. :7�-�-y
I-t�aw1 1000 IN\I•
o�sT. 1��. GAL,. 488 I
2It . Io0c> INS 48,G
TANK /b•� ;
GA.L. . .
5a►�o�� LEAcu
PIT - INV. ..."INY.. .. ...___...
WASutiD i ..
CDQ�I� STvNE EL
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