HomeMy WebLinkAbout0030 FOX HOLLOW LANE - Health 30 FOX HOLLOW LANE, OSTERVILLE
A=145-006.012
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TOWN OF BARNST ABLE
L6CATIC1N SEWAGE #
VILI' AGE ASSESSO 'S'MAP & LO /
zNSPEC7Dg'.5 NAME&PHONE NO.
SEPTIC TANK CAPACITY �04�Sa/
i� a
BLEACHING FACILTTY: (type) �f, (size)
NO. OF BEDROOMS
BUILDER O OWNE _
PERMITDATE: 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
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TOWNo° _ OF BARNIS�TABLE _
LOCATION U `�'1#Q `J2(&/ 'P SEWAGE #
VII:!.AGE ASSESSOR'S MAP & LOT
IQL--Ut&-try 1'Z
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Z-20' 1-e
LEACHING FACILITY: (type) *t�T (size) Vxa
NO.OF BEDROOMS— AV -�
BUILDER OR OWNER
PERMIT DATE: �`�ZZ COMPLIANCE DATE: 6-z`/- 9�
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
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A2 - 132 ''
No. 16 —3 7J Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes
01pplication for Migonl *p5tem Com9trurtton VCrmtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. FOY u.> (40 1 Owner's Name,Address and Tel.No. t ,
Assessor's Map/Parcel L _D�\V LC�, 1
l ti� 604 -v 1
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
t 0-Gwr�p Se a L
�0 'g�A�Ta✓ QQ � �.N.S
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `263 Q gallons per day. Calculated daily flow �✓`''�� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Sr�'i 5 07YO 5 t4kNQ bt,� Type of S.A.S.
Description of Soil V S )
Nature of Repairs or Alterations(Answer when applicable) .S V-5ro- O C-e—
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 C de and not to place the system in operation until a Certifi-
cate of Compliance has Issued by t u 111
Signed- .w-- Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 7S� Date Issued E 2 2
No. 3 Fee '
_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Yes
01ppCication for �Digaal *pgtern Congtruction permit
i
Application for a.Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. .31D J=UZ( `pv J l.yJ Owner's Name,Address and Tel.No.
pSTcrv��\�
Assessor's Map/Parcel "I "G V C CA- �
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
V\% 0—ut.�Se a L''(
;;>o ��A�Ts✓ QQ C� S
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No; of Persons Showers( ) Cafeteria( )
Other Fixtures `
i
Design Flow Z"Zn gallons per day.,Calculated'daily flow
g .
Plan Date y iNumber of sheets "' Revision Date
Title - =r
w F
' Size of Septic Tank tt.J Type of S.A.S. At ��Cc,n«�t �1_�- tLt����
Description of Soil
At
Nature of Repairs or Alterations(Answer when applicable) S tn.ST`pA,
.`( S t 1 e
Date-last inspected:
Agreement: }
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accoidance.kwith the provisions of Title 5 of the Environmental C de and not to place the system in operation until a Certifi-
cate of Compliance has b ue y t i
f
Signed Date
Application Approved by Date L Z—9
Application Disapproved for the fo lowing reasons
Permit IVo�T^!�—�7$� Date Issued 6
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by —
at , ts G,I " - \ has en constructed in accordant
with the provisions of Title 5 and the for Disposal System Construction Permit No. �9 —37' dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syste 1 functi7psZsOigntteI
Date /--2,#—J 1" Inspector
No. —3 2r ----------------Fee
t
r_ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
=igoml *pgtem tongtruction Vermit
Permission is hereby granted to Construct( )Repair( )Upgrade(% }Abandon( )
System located at �-1(7 n�c \ ``c� [35T V_yk\Ke
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.
Provided: Construction must be completed within three years of the date of this it.
Date: �9 ` 2 Z —9� Approved by
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10/9/97
NOTICE: This Form Is To Be;Used For the Repair Of Failed
N Septic
ep c Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION-FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
z ENGINEERED PLANS)
J.
hereby certify that the application for disposal works
t' `x CO
ristnaction permit signed by me dated concerning the
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166ted St, +` C 0., OUJ 09� `f�
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,
{ ew property0.. 1- \ meets all of the
�{ following critena4 �..�
z .
11//�mere are no wetlands located within 100 feet of the proposed leaching facility t
"�.
/ • There are no private wells within 150 feet of the proposed septic system f
There is no increase in flow and/or change in use proposed
1
�� � There are fio variances requested or needed.
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f the sed leachin" facili will be located within 250 feet of an wetlands, a bottom of the `J/ t P !; tYr .. y th
s proposed leaching facility will DW be located less than fourteen(14)feet above the maximum adjusted
groundwater table-elevation.
x
x y Please complete the following:
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f A)Top of Ground Elevatiori(according to the Engineering Division G.I.S.map) a> �
r s st
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B)Observed Groundwater Table Elevation(according to Health Division well map) 5
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LICENSED SEPTIC WSTEM INSTALLER THE TOWN OF$ARNSTABLE NUMBER `
���§.st�4��5x�� lW� v, M1 s ..,-E C `�.:-. .; r'vo •.- , ,.. . . .-. ... `. '_ "` .'`_ � ,. , t.':£ r t��,'1F
f [Attach it sketch plan ofthe proposed system.Also if the licensed installer posesses a certirted plot plan+
{ this plan should be'submitted].
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i �'1""w'jY:Min.•r.l:Fs4•Yp`M...FMG+,M1.�•.M1.fwnVnv_9MY".•-er•t'xNnwNw+4.'ye"..FY s. ..M. .. s .s ..n .s.F! F s w �r rs ,M,
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132
A /33 A3
TOWN OF BA.RNSTABLE
LOCATION 0 rat HoL t�.0 a„4. SEWAGE #
VILLAGE t2 t L10--tt\� ASSESSOR'S MAP & LOT��S-vcXe—i� Z.
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
dac�
LEACHING FACILITY: (type) �f t.� 'r (size) X X f
NO.OF BEDROOMS AV -�
BUILDER OR OWNER
PERMTTDATE: ✓ZZ✓% 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
No.. � Fizim.... ..............7
THE COMMONWEALTH OF MASSACHUSETTS
AV
�eR® �Fa.-sfm
— LTH'.. ...........OF....... /...Y. �` ................
ApplirFation for Disposal Works Tnnitrnrtiun jhrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...(0-Y—P.J.0..... .....
�OT* .../ sl'.
o,a io - r or Lot No.
- -----------------------------•---- -----.....-----.-•-..-- -------•--.._......--------------..---
y �.Q}aner / �� .�rAddress /. ..
a •---�rl/Y1 �......:C�..�/. ......--...-•-•--•------------------------------ --- --•-._1��1 ........ -------• ........
Installer Address
dType of Building Size Lot...........................Sq. feet
U' I Dwelling`.—No. of Bedrooms.____............................Expansion Attic ( ) Garbage Grinder ( )
pa-, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ....................... ..
------------------------------------------------------------ --------------------------- ---------------------------
W Design Flow.................................00.��n. allons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity4:,16�'.galIons 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 ( )
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 Description of Soil........................................................................................................................................................................
U -----•----•----•--•----•------------------•----••-•-••--•--•----•--•-----•------•-•----......-•-••-------•-------------•-----••----------•---------•---•---- ---•----•-•---••-•---- ..................
Nature of Repairs or Alterations—A s er when livable._ ..._
U P �L� .��. — —
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI'i LT4,� 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 boaro of health. A,
Signed•- ✓ .. ....----••---------- ...... � ..... J 1
Date
Application Approved BY = ---to....
Date
Application Disapproved for the following reasons:.. ...........................................................................................................
...................................... ----------------•-------------•-------------....--------•-----------•---•---•--------•----------•-----•----- --- ---------------------------------
f Date
Permit No. 2.q---r-- ................. Issued......... 7 -- ----
� Date
l 11.. "IY F>s
THE COMMONWEALTH OF MASSACHUSETTS
tl�IOARDf , ,�.......OF......_ 9 ��� 1.
ApVliration for Disposal Works Taustrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....1:...... ..I .r.W.._..0 Lhl� �s .....--•--------•-----------------••-------- ----....--•------------................-------•---•
oc do - •dd s or Lot No.
....1 .1 ._.. .1` . ------•---------------------------- ---------------.............................---....
Owner Address
W
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms.....-- ..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures .............
W Design Flow.................................. gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacit,. �� .gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length...,:.............. Total leaching area....................sq. ft.
3 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. 1................minutes per inch Depth of Test Pit___.__..........__.. Depth to ground water........................
ri, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •••---------••------•---•••--...._....••-••-•--••-•-•-•---------•-••••••----•.......................................•-------------•-•------•-•---•-•-••_----
0 Description of Soil......................................................................................................................................................•---•------_-----
V .._..•-•-•---•-•---•-•--•-••-•-•••-••-•-------•---•--•••-•-•--•-.......-•---••--•-•-•-•---•-....•-•••----•---•------•---•----••••----•----•-•---•----•---------•-•-•---------------- ••-----•--•-----
W .......................... -----------------------------------------------•------------•----------------------- y
x 1 �„�
n ,
U Nature of Repairs or Alterations—A wer when applicable...__ �.� �. �......
Agreement: - �
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLIE, 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.
Signed1 -.....�--------------- .................... ................................
LA Date
Application Approved By ��!`��''i... -= -- ---
Date
Application Disapproved for the following reasons:. ----------•--------••-•---------•-•------------ ...................
--.......-•----------------•-•-------•-....------------------------------------------------------...-------••••--••-•--•-••••---•-•------•-•----•••••-• •--•• .........................................
Date
Permit No.--- ••`•-�...... ------. Issued------ t
Date
THE COMMONWEALTH OF MASSACHUSETTS
,(�1 OARW�H,jE LTFK......... ... .!.V. -......OF.... :.V/�,��`/.../�. ..........................
Cprrtif iratr of Toutpliatur
by
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (y ) or Repaired ( )
........................ . ........ ••
--.
s alter
1 0/
r . ........-------I..... ........ ..................
at.... ......... ..... ..6. ...................... --- Z,/V.
has been installed in accordance with the provisions of 1' "+ 5 of Th S•ate Sanitary IRA
as es ri ed in the
application for Disposal Works Construction Permit N o.__
T ..�. dated------ - - ----------------•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS t8E® AS A G8J TEE HAT THE
SYSTEM WILL F C ON SATISFACTORY.
DATE.....�/ � �P/................................... Inspector....---- ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEAL
.......... 0 F M-4 A ....yYV.......••- � .........................
No •••• FEE... ...................
Disposal Works TUInstrudion rrmi#
Permissin 's hereby granted.................................................................................................................,..........-•-•..............
to Const�ju-ct� ) or a air ( ) an I dividlulal�Sewage Dis os�Il S st �' C. r
at No.•---!.. to -- r1 f i I �= / ------- I.::......
Street I f ated-•9
as shown on the application for Disposal Works Construction Permit Nc( __. _�___, .-------_-•--
/
----------------------------------------------------------------------------------------••••---••••.
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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