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HomeMy WebLinkAbout0433 LINCOLN ROAD EXTENSION - Health 4 B Lincoln Road ext. Hyannis A=271 - 025 a TOWN OF BARNSTABLE LOCATION33 ,�l�C6/�moo. s,�( SEWAGE VILLAGE yt ��,�5 ASSESSOR'S MAP&PARCEL497/1� INSTALLER'S NAME&PHONE NOe,40Wikf ( SEPTIC TANK CAPACITY l 1LYJ gQI/on �7,7eJ14 tic LEACHI N G FACILITY: (type�(/�gA�,�,F;/T��e� NO.OFB��E..DROOMS 3 O WNER'h,,e4et Y Z G PERMIT DATE: 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 �s �'s' �r �. ��� � �� �G (� � ` o 1C W �, � �C t,a N Ca ,c .�, �, ,� �- � C�a, U d1 "� c .r �' t--' Na. � � ��� FEE -15-® ` COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONS' CTION PERM,IT Application for a Permit to Construct( ) Repair( ) Upgrade( AbandonO Complete System ❑Individual Components Location t ! Owner's NameiATWA - Map/Parcel: Z-11 Z,5 U Address I Lot# Telephone# Installer's Name Designer's Name. Address ' �� Address W Telephone# Telephone# 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 req iced) gpd Calculated design flow Design Dow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) ��L> LJV Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS �C The undersi agr es to inst the ab a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agre o n to place syst in operation until a Certificate`o Co pliance has been issued by the Board of Health. Signed' Date 6 L Inspections •'"""'i.� .,w ...-^-I". w.4n ldT ri a:�r-' W-:.,•-. ....?.:^w'+"^TK�a 4.+..] ., T. - . N".♦- No. ��9-I" ) FEE%/-15 �a _ COMMO,NWFALTH OF MASSACHUSETTS Board of Health,- MA. '► - APPLICATION FOR DISPOSAL SYSTEM CONS- I -T TION-PERM,IT Application for a Permit to Construct( Repair(-) UpgradeO•A� bandc�nO - C' omplete System ❑Individual Components " Location ` Owner's Name-+4': � Map/Parcel# "" �. ►� Address v Lot# .--A Telephone# Installer's Name iy �" Designer's Name IN- Address �' `\ �✓ V�b Address "yi1..FgwL Telephone# Telephone# ��[ Type of.Building Lot Size sq.ft. Dwelling-No. of Bedrooms Garbage grinder( Other-Type of Building No.of persons ShoweA Cafeteria( ) IAOther Fixtures Design Flow(mint r q.ired) gpd Calculated design flow. A Design flow pro ided gPd Plan:. Date, Number of sheets Revision Date Title 1 f !l Description`of Soils � .a Uy 1 P Soil Evaluator Form No . Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS ' �A{ f The undersi e'c� gr es to mstail�the abo�e described Individual Sewage,Disposal System in accordance with the provisions of TITLE 5 and further a e-s to on Go lace fhe s to ul operation until a Certificate o Co Hance has u issued gr p ys p been iss ed li` the Board of Health. P Y Si ned ►�f I t a g. Date jnSpe.CtiQi1:S - 1 � t _`u.'!t3r�'.1N`COZ?UO{;} l�a;�`d.t UOtur,6c�r.Cz` "`.jl�.'?:�:C L^p:.'7 V*?f�OCu.`',^., :^2�.t.'iiU�,,^t.�.•-.�Pi)y�..0 ut; "-.': "vu'�c'? t '�r.ccYc�'JCCtii\n.Crf..C-���i�f,c:0',fi' ., No. �1 i 1 FEE / —� C®MMONWEALTWOE MASSA HUSETTS qyd ry F "' ��'A - Board of Health, MA CERTIf f l,�E OF COMPLIANCE Description es tion of Work: n .�0 I dividual Com onent s ©Com e ` r _ P , p � ) �. Complete System The undersigned hereby certify that.the:Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned byy C^ ' at 44 �+,,� v .. • 'Y Y � Y has been:installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated § Approved Design Flow,__ agp ) Installer- �l ADw 6 d p P g 4.,.�`, kA Inspectorx: .Designer. � � The issuance of this permit shall not be,construed as a guarantee that the system will function as designed. ..,eJrr, _CC^.�.ra..-..(':r.r,-C4h Vtic"•:•-hCt. .•l r:�jC"?ltt G0.'.J� �,...:.r,n)_f��:'s0.:,,.cat-Gt uC J.LC. �..C:uVu{;p�GpOdn�'� f,,. .._.. - ..- - No A 1A, /* FEE COMMONWEALTH OF MASSA .HUSETTS, .w Board t f Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( )� Repair(V) <pgrade( ) Abandon( ) an individual sewage disposal system L' at UwLOU4A % vx�// , as described in the application for.sal System Construction Permit No 'U-1 , datedrI ded: Construction shall be completed within three years of the date of this perm All/loeditions must be m'Rev,5/96 A.M.Sulkin Co.CtWestown,MA Date/.//2&11 Board of Health F T \, • �".. Town of Barnstable �•++E Regulatory Services Richard V. Scali, Interim Director Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems Property Address:— Assessor's Map\Parcel: 2-1 l z Property Owners Name: Qk In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an "x" in the applicable box next to each line certifying the information. Yes � ❑-1 have been provided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and the specific technology letter) I have been provided with the Owner's Manual I have been provided with the Operation and Maintenance Manual ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) and the Approval ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) If the design does not provide for the use of garbage grinders, the restriction is understood and accepted ❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303 1 , 14'eX` -. agree to comply with all terms and conditions above. Property Owners printed name Tr6p'6rtt0wners Signature Date Note: This form must be submitted along with the septic system disposal works permit application for all IXA systems including new construction, repairs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\IA homeowner certification.doc 'Town of Barnstable P# s� Department of Regulatory Services RAHKgrABM Public Health Division Date •639 . 200 Main Street,Hyannis MA 02601 NUd _ Date Scheduled TimeL Fee Pd. Soil Suitability Assess �nt for S w ag'Disposal Performed By. V 1 .�� Witnessed By: LOCATION & GENERAL INFO ON _ Location Address j OWC � p� m 0-1 Owner's Name�,�-�()� Address Assessor's Map/Parcel: ®�� . Engineer's Name,—� i NEW CONSTRUCTION Telephone# Ve l3� / 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) 1 r Parent material(geologic) th to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE _v �] 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 -�..�.�.- __TT.I.T!-V.l1T ♦.TT.!_\1T.TTl'1T.___..��.-._. _1..���. ,.„.4... ��.-..�_. 1 DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil ther a Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel 14 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) 619M P62 DEEP OBSERVATION HOLE,LO_G= _Hole# Depth from Soil Horizon Soil Texture, Soil Color wry Soil T Other wj � Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) 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) Flood Insurance Rate May: Above 500 year flood boundary No_ Yes ZZWi 01 No Y Town of Barnstable � Ta Regulatory Services Richard V.Scali,Interim Director UgNhASM � AM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form O 7 C Date: lxloSewage Permit# Assessor's Map'Parc Designer: � f7 Installer. V- . Address: P(bT Address: M00,;le � a issued was permit to install a _ I _ (da ) (installer) �p septic system at LAI _ 4 based on a design drawn by (address) A � dated (design") 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 construc;;µa�__.��liance with the terms of the IAA approval letters (if applicable) �+►►i°° t��OF��q�. DAVID ss 0`t ON (Instal ez's ignature) $ No. s v (Design s Signature)-/- (Affix Designer s Stamp Here) PLEASE RETURN TO BARNST. 'F 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�Dwigncs Certification Form Rev 8-14-13.doc i 1 k j ASSESSORS MAP: TEST � HOLE = LOGS* - I 1 *&)ard PARCEL; 1) The installation shall comps with Title V and `l'own oF� of QI I � C [ ealth Regulations. i SOIL EVALUATOR; i FLOOD ZONE: �-_T• ,1(� �jl, ' ., . .__ - __ _ __..__..___.__-.__.__. __ WI TNESS: 4�1 2) The installer`shall verify the location of utilities,sewer inverts and septic our REFERENCE: I • >� ��Z� DATE. components prior to installation and setting base elevations. PERCOLATION AT .� lv�� t 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot.The first t ; �^_-� 'QV�`"-I Z�IO�� _ 46 two feet out of the d-box to the leaching shall be level. I j (D 4) .This plan is not to be utilized for property line determination nor any other j purpose other than the proposed system installation. �o 5) All septic components must meet Title V specifications. k, 4 — 6) Parking shall not be constructed over H l0 septic components. j f ; �° I 7) The property is bounded by property corners and property lines. ,�2tJ fc� � n �' � t0 �< < ' 8) The property owner shall review design considerations to approve of total 1 LOCATION MAP ibt� ;. design,flow and numbet of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. ' p o 9) The'existing leaching or cesspools shall be primped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall J �n 7 - I l be removed along with contaminated soil and replaced with clean sand per I ,� _ Title V specs. I � �r g , 10)System components to be 10.feet from water line. Sewer lines crossing the _��• _ _ water line shall be sleeved with 4 inch SCI 140 PVC with ends routed if applicable.. The proposed SAS is being installed below the water service w GL , M t1) line. The line is to be sleeved as aforementioned and maintained in place. SEPTIC SYSTEM DESIGN 1 m �,2 11) 1f a garbage grinder exists it is to be removed and is the responsibility of the ' owner to ensure such. ' 1 2 f I i j FLOW EST I MATE 1_)The installer is to take caution in excavation around the as line if such I /C;) }-- exists. 13)The installer shall veri the location, uanti and elevation of the sewer 1 i _BEDROOMS, A 0 GAL/DAY/BEDROOM - GAL/DAY I _ . 9 ty i lines exiting the dwelling"prior to the installation. i 14 This Ian is representative only that a system can fit on aproperly ( j <- SEPTIC TANK - I P P Y Y meeting i i Title V requirements. I I 1'LGAL/DAY x 2 DAYS .�(�iL GAL i 1 USE GALLON SEPTIC TANK D 1-�E�L� � __W _-. .fib ( a►� _ �- - � SOIL ABSORPTIOM SYSTEM - ! j O O O I� - � Gam__ owl v� r�irr� fw l�a�� <<` �N A,14 w I�l�l' o -.---_.T_._.._..- DAVID - - MASCJP! �/ ^� �J7. _ LZ! �: Vwffx, S E P I SY.�'T M SECT I ON +4;r -1 _._ ow A z - �� I I (]1 j 150� GAL. t� � . � :. -- Z,�gj //�� SEP IC_TANK X f I ��(Ol. � � _g�4G�C. il,l._ tW riLTr_4M Vtti}�S i = IktST�p.�l.C� .'��i,Q..� y4.i,,ItJ' ' ` �(ZD V�!•I 15 �� i I j SITE AND SEWAGE PLAN LOCATII ON `�2'J �--IWDUV,4 �, D T, I PREPARED FOR : C �I�lj^l)q/ CDIr�I��T, a SCALE: C'd - DAV I D B ', MASON F6 DATE ° DBC E�1V IONMENiTAL DESIGNS 2 - 1 ' PATE HEALTH AGENT EAST SANDW I CH # MA ( 50811 , 833- 2177 Z ; j 0 1 'Z i : 1 - ----- - ASSESSORS MAP: j _ TEST H 0 L E -- -- ---- --- , LOGS' PARCEL: .. -- __ I) The installation shall comt7� with Title V an�l '('own uf )ard of t OOD ZONE: lOr: SOIL EVALUATOR: P C Health Regulations. FL NE -` P�L�L '�L'�i . --_-----____._.___.__ — - - - -_--- _ WITNESS;, 4� 2) The installer shall verify the location of utilities,sewer inverts and septic , REFERENCE.. �3Z �Z DATE: ; components prior to installation and setting base elevations. : PERCOLATION ATE s .� lHt ► • . ; 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot.The first i Z lo 1� �l' "'� __. ---- two lbet out of the d-box to the lcachin shall a level. { i� g II b I I , 4) This plan is not to be utilized for property line determination nor any other ��y01 purpose other than the proposed system installation. o5) All septic components must meet Title V specifications. I ` 6) Parkin shall not be constructed over H 10 septic components. g p p �° 7) The property is bounded by property corners and property lines. j :So/ > ��G > t le� � '' b �� �n 8) The property owner shall review design considerations to approve of total k1V �1V design.flow and numbet•of bedrooms to be considered for deli Receipt ; LOCATION MAP t7� �� Z (} n g �• p of payment for the plan and installation based on the plan shalt be deemed approval of the design flow by the owner. p o ,, ' 9) The'existing leaching or cesspools shall be pumped and filled with material Gti (V ��` per Title V abandonment procedures. Those within the proposed SAS shall ; n� T1� . I / �`7 be removed along with contaminated soil and replaced with clean sand per ! SAW Z~! Title V specs. N115C7 �I I , tl �y,, � U"� g4 0 , 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SC1140 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service I t" 4�' It( line. The line is to be sleeved as aforementioned and maintained in place. i I SEPTIC SYSTEM DESIGN 1 1) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. G • FLOW ESTIMATE ! 12)The installer is to take caution in excavation around the gas line if such exists. ! i 13)The installer shalt veri t BEDROOMS AT .) , ,GAL/DAY/BEDROOM -/ GAL/DAY . . fY_he•location,quantity and elevation of the sewer j lines exiting the dwelling"rior to the installation. { SEPTIC TANK : 14)This plan is representative only that a system can fit on a property meeting F i Title V requirements. ( ! 1'LGAL/DAY z 2 DAYS -� GAL USE GALLOA -SEPTIC TANK D k.��L ' 0 . 0 —/ SOIL ABSORV 1 ON SYSTEM - � _ _ . 10 owl v1% �I'il�}�ar�r� lu g ( � ►l�' IWy I' �"OF,t� . 1 _ - _ - J � � o MASON En v ,p�No.1Os 6� �,•-i • j ►�' _ _ s SEP I SYS� M SECT I ON z I 1 Al4 �' / / C� - ' 1% k i { v - � ql, i k:;I►I qq Am I i 10 7,Zo h t; f 15oc� " GAL t �7 SEP I C ,TANK r { bl (a I TE AND SEWAGE PLAN -- ( LOCATI ON : t I PREPARED FOR : C �I�l�l)}l Cotx1c cr I � Ft G I , — DAV I D B­ MASON F6 DATE t� 1l I s ----- DBC ENV I RONMENliAL DES I GNS DATE HEALTH AOEN1' EAST SANDWICH MA i ( 508 833- 2177