HomeMy WebLinkAbout1676 SANTUIT-NEWTOWN ROAD - Health 16 66 SAN711I i-NEId 70WN ROAD CU i 11I
� �! TOWN OF BARNSTABLE
1
LOCATION h SEWAGE#
VILLAGE. Co�u/'�- ASSESSOR'S MAP.&LOT
INSTALLER'S NAME&PHONE NO. �r � 1 �o�s 771-93,4�
SEPTIC TANK CAPACITY /Vm
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER S G
PERMIT DATE: /� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet J
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �-
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THE COMMONWEALTH OF MASSACHUSETTS
3
0 BOAR® OF HEALTH TOWN OF BARNSTABLE
Appliratiuu for Di�5pwial Work.6 C owitrurthin rautit
Application is hereby made for a Permit to Construct ( ) or Repair P� an Individual Sewage Disposal
System at:
/40. � ,
[S, ,1,14l�l oc t00,1
ion-:�d J!/// A,`-W 7V"r j 4&." or Lot No.74
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wncr ""a�ddress,57 .......- ... ..........................
Installer / Address
d Type•of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms---
__`............................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a'' Other fixtures -----•--•-------•---------•--- -
---- ----- ----- •------- -•------••--....... ------
W Design Flow___..__...__._________________gallons per person per day. Total daily flow..__.- 3��-----....._.._._.___gallons.
WSeptic Tank—Liquid capacity/.SQ..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........................
40 Test Pit No. 2----------------minutes per inch Depth of Test Pit..............._.... Depth to ground water........................
C4 ........................----.................................................................................................................................
0 Description of Soil........................................................................................................................................................................
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W ••--•••-•-------------------••----•-....---•-------•---...-------------- ---------------•-•-------•-------------•----•------------------------------••-••••••----•••••--•......•---••......•--•------••.
VNature of Repairs or Alterations—Answer when applicable am`* ._.-4:...�����r(�/ _�-:7',e—
/�1 �,'U t.....................J --
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental de—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance h een issued t board of health.
Si �J
ne �- ®�'/ .
4Appl • Dace
ication.
Approved Y -.... .._. ............. ...�L. .�1 r-�-.-.-.-.-..-.e
Application Disapproved for the following reason'r: -------------------------------------------------------------------------------------------......--------------------------
--------------------------- ---- -- ------------------ ----------------------------------------------------------------------------- ------------------------------------------------------------- -------------------------------------
q q Dace
Permit No. .. .�! .�..1............................... Issued ........................................
Dace
No ..S_._.�11 ........`.....................
THE COMMONWEALTH OF MASSACHUSETTS
{ BOARD OF HEALTH
TOWN OF BARNSTABLE
Alip iratiuit for Divi-putiul lVurk,i Towitrurtivat thrmit
Application is hereby made for a Permit to Construct ( ) or Repair (DL) an Individual Sewage Disposal
System at
v�I CG t�.l�-1
..... 6 ••••N--••-•••-•--•••-•••....••----•-• -••••-•.i.... •---------�-=.G i c>--'---'----------------------•----...--•--•---....•.........----...-----
/SL) ocation- " j ass/ 'Ai
�� or Lot No. I_
- ... ill T-v-•1-•-.....
Owner Address
s
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms-__ ___f�________________________Expansion Attic ( ) Garbage Grinder ( )
PA Other—Type of Building ... No. of persons-----------------------:.... Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ _ _
W Design Flow................57�-_________________gallons per person per day. Total daily flow_.___._._-7_��---d_____.____..__._..--'gallons.
WSeptic Tank—Liquid capacity/Sno_-gallons Length---------------- Width__-__-�-___-. Diameter---------------- Depth................
x Disposal Trench—No- -------/......._._ Width-5------------- _ _____-_-___ 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 ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit.-.----------------- Depth to ground water........................
44 Test Pit No. 2.................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
0 --------------------------------------------------------------------------------------------•-•-•--------------
•-------------------------
------•------
0 Description of Soil................................................................................................................................................ -------•-••-•-•--•-----
x
w
U Nature of Repairs or Alterations—Answer when applicable.._/N-s%"'z __-�__--/�`�!� - -:f//T►_4-7` w1L
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ro"Je I-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has'been issued th board of health.
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Sl ned _../�LJ� --(/---t _........
�` f Date
Application Approved ......-- ...... ---------------------- ,0 � .._-......
Date
Application Disapproved for the following reasons- ------ -- -----------------------------..-.----..-..-------------_............ ........ ...................................
Dace
PermitNo. ------- ------------------- Issued ---------------------------------------------------------
Date
a.._>., ----®®. -------ome®._,_o___——---I—mom.—oe---ve. --�
THE COMMONWEALTH OF MASSACHUSETTS 0 Z,LI —Q
r"
BOARD OF HEALTH
TOWN OF BARNSTABLE
Gex#ifi ate of Q-1omplinure
THIS IS TO CERTIFY, Thi b Individual Sewage Disposal System co..nstructed ( ) or Repaired
by ....... ..........._ . .. .... .....-. '' 5`i /c /u,a- --........_........... ....
at ........ .. ...... _ 161-�&.-- -- EJ. i Gu!-------------
- ......f i
has been installed id accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No- --------------__............................ dated ......................----------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE DATE....................... .... L....... .�....-... _.. --- Inspector ------------- ,_....... �).
_._____a___________ _„_______,_---—_,_---____.___—__ l _,�__. _—__._.,_,...._ sue------___ ____
?,
THE COMMONWEALTH OF MASSACHUSETTS �6
BOARD OF HEALTH
q TOWN OF BARNSTABLE
No.....I..�......��� ! FEE........................
Mipnual Turku �laaiutr uan prmit
Permission is hereby granted--------------------_______4.✓�^._.? ------ _"�S _....�'^.
............................................
to Construct ( ) or Repair (jL) an Individual Sewage Disposal System
at No... b 7b ^Jf.w1.Z.�'J #1 ;= E- v------'---------------------------------'----------•---•-----_
Street r.•
as shown on the application for Disposal Works Construction Permit No- _.-______________ _I _- -._ -..
rf l 7/j Dated ct ��
/ Board of'Health
DATE.... ----------------------------------------------------------
FORM 36508 HOBBS A WARREN.INC..PUBLISHERS
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CON HIUC CON I'EltMl'1' (WI'I'110U'F DESIGNED PLANS)
I, 2aQ 1�o/Ccst�T7 , hereby certify that the application for disposal works
construction permit signed by me dated �/k7j'-- , concerning the
property located at //7f- p,JS*.t-70,Jf.l Q CcrU (7- meets all of the
following criteria:
• —There
are no wetlands within 300 feet of the proposed septic system
There are nb private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
C, • There is no increase in now and/or change in use proposed
✓/ • There are no variances requested or needed.
SIGNED: DATE:
LICENSED SEPTIC SYSTE INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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