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HomeMy WebLinkAbout0040 BLACKTHORN ROAD - Health 40 BLACKTHORNS ROAD MARSTONS MILLS A = 046 076 R TOWN OF BARNSTABLE LOCATION T� li e1r rf7 g2.4 / SEWAGE # 41 Ol VILLAGEJ�UvJf" 441 111 ASSESSOR'S MAP & LOT bgG-b- INSTALLER'S NAME&PHONE NO. �fJ SEPTIC TANK CAPACITY ZOO o LEACHING FACILITY: (type) size) / � }{ NO.OF BEDROOMS ,,// BUILDER OR OWNER �/ /ie 62" 40,00�O T 7-,e PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: M 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 �_ v'T /�� No. 7fG�� 7/ Fee J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ve/s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppfication for �Diopozal 6pgtern Conotruction Permit Application for a Permit to Construct )Repair(Upgrade( )Abandon( ) ED Complete System ❑Individual Components Location Address or Lot No. ilCj '7"!y/IJnN Owner's Name,Address and Tel. o. Assessor's Map/Parcel/ //_ 0 r? _ A G N Installer's Name,Address,and Tel.No. 43@ .O �20 Designer's Name,Address and Tel.No. C<j J OR IC 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 l l a gallons per day. Calculated daily flow U gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer whpn 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 Certifi- cate of Compliance has been iss ed by this and of Health. Signed Date Application Approved by r Date,-' / l Application Disapproved for the following reasons Permit No. �i `LUl' Date Issued c TOWN OF BARNSSTTABLE LOCATION !� SEWAGE# j VILLAGE r//J,� �AiSSESSOR'S MAP &LOTQg61'-0� INSTALLER'S.NAME&PHONE NO. SEPTIC TANK CAPACITY Zd O o LEACHING FACILITY: (type) `SG'D i'.y `nH/�lt�C��;('size) ^ ZX / x NO.OF BEDROOMS � - BUILDER OR OWNER &e/e n/ G Ga T 7-,e PERMITDATE: J��S— I COMPLIANCE DATE: ez Separation Distance Between the: Maximum Adjusted vroundwater 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 r d ' ,' } No. Fee,!5 THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer: les PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS 2pprtcatton for 30top'ogal bpgtem Conotructtott`Perrn t" Application for a Permit to Construct{ . )Repair(Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. V& n4c)- 77/cw N Owner's Name,Address and Tel.No. Assessor'sMap/Pazcel 6 or? � v GN / r Installer's Name,Address,and Tel.No. �. � ��O Designer's Name,Address and Tel-Nod Type of Building: , Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder(W Other Type of.Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow / U gallons per day. Calculated daily flow y V 0 gallons. "} Plan Date.) Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. f% Description of Soil .Nature of Repairs or Alterations(Answer when applicable) /✓� G i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described'on-site sewage disposal.system Y. in accordance with the provisions of Title 5 of the$nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issped by this and of Health. Signed Zlam Date Application Approved by Application Disapproved for the following reasons Permit No. Is OO/_ R'F Date Issued ------------------1, --------------------- , THE COMMONWEALTH OF MASSACHUSETTS FX BARNSTABLE, MASSACHUSETTS Certif irate of Compliance THIS IS TO RTIF(,hat the On-site Sewage Di osal System Constructed Repaired( )Upgraded( ) Abandoned( )by Gv r?— at C) L 1 C G 111 J has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction�Pe o. dated Installer e o Designer The issuance of this p t hall not be construed as a guarantee that the sy ill f�ct' as des. d. Date —� G/ Inspector r ------------------------------------- No. Fee S'Z/-, ., THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Mt-opogar bpetem Cow6truction j3ermitt Permission is hereby granted to Co struct( �v Rg air( )Up rad ( )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 5 and the followinglocal provisions or special conditions. Provided:Constru tion must be within three years of the date of tht. f Date: /� �-11/ Approved I/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERIIMIT (WITHOUT DESIGNED PLANS) I, ���� l'I S�P ►'t , hereby certify that the application for disposal works construction permit signed by me dated S-I S`f o ) concerning the property located at y O /Ae k Edon N a-'4 P4 ig S meets all of the following criteria: J • This failed system is connected to a residential dwelling only. There are no commercial or business 1 uses associated with the dwelling. J• 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: A) Top of Ground Surface Elevation (using GIS information) © ! B) G.W. Elevation +the MAX. High G.W. Adjustment . _ 50 DIFFERENCE BETWEEN A and B � SIGNED Z�A— —l^' DATE: .S '/SG)• [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert r 11/ V LOCATION SEWAGE PERMIT 140. / d%�q3o S 1,cGkT1bfc,j -7e `/O VILXAGE �l� 's-o pie P///s INSTALLER'S NAME & ADDRESS aro ©vn co /'✓i�k°GJ�C t UILDE R OR g�OWNER mi A l, r,o7�T�rC' DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �1 S NW K J SO 7d' No Aj.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD O HE ............;�_�. .:...........OF.......... .. ............................. Appliration for Dispaiial Works Tomitrudion 11omit Application is hereby made for a Permit to Construct Lll-**'O'r Repair an Individual Sewage Disposal S t t �,Y .. ......... ... ............. . ............................ . ... Location-Address ....................TLzr................................... Owner Address .................................................... .................................................................................................. Installer Address Type of Building Size Lot----------------------------Sq. fget U Dwelling—No. of Bedrocms... Expansion Attic Garbage Grinder oh) ------------------------------- Other—Type of Building ............................ No. of persons.....__..................... Showers Cafeteria Other fixtures ............................... ­-----/-----­------­----------------- W72y"a;-------------------------------------------------------- Design Flow----ZZ��................. gallons per-peps" �'e'Yday. Total daily flow........... ................90011s. 9 Septic Tank—Liquid capacit;� gallons Length 7��......... Width---%5......... Diameter................ Depth...-/... Disposal Trench—No..................... Width............._._.... Total Length......_............ Total leaching area.................---sq. ft. Seepage Pit No......-2. ........ Diameter./ ... Depth below inlet...4-.f_.9?t.... TotaL4faching area.&��? sq. ft. Z Other Distribution box Dosing tank /0 2 77— aPercolation Test Result Performed by_Z2jPt_---�-_J..... .......... Test Pit No. I.. . ....minutesperinch Depth of Test Pit.................... Depth to ground water.___..__...._......____. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ..........:L--,------ ........... 0 Description of Soil L. . ... ... . . . ... ...... ... ...... ..............JQ.. ....... U !9.- --------- ....................­­............................................................................... . ........ ----------------------------- U Nature of Repairs or Alterations—Answer when appll* l............. ----------------------------------------------------------------------------------------------------------............................................................................. . .... Agreement: The undersigned agrees to install the afored cr' e ividual Se Disposal System in accordance with the provisions of TJITA 1Z- 5 of the State Sanitary Co — The undersig d f rth agrees not to place the system in operation until a Certificate of Compliance has be ' su by th o of I . ... . ............ ........... ......................................... ...... .. ....... D e ------- Application Approved By......... .. . .. ...IA_14. .. ......................... .... ... ..................a. Date Application Disapproved for the fo, owing r ons:................................................................................................................ .........................................................................................................I............................................................................................... ------- 7 e /_// ate- * ��Permit No........................................................ Issued.. Z / ................................ Date No. D._....... Fizs.._..,Z., ... THE COMMONWEALTH OF MASSACHUSETTS BOARD X 1-1E L tt '�------------- .:.-..-... > :-.*...---------.._....._....--•-- Appliratiun for Disposal Works Tontrurtion Vrrutit Application is heretfy made-for a Permit to Construct (4­1 6r-Repair ( ) an Individual Sewage Disposal Sys at: ,r Location-Adder Wa ..... - .t,.�L+Installe rs ZZ. ...................... �•_pi o "Owner -----------------•--...........---- -----------------------_- --------Ad--d r-e--s-s-__------------------ --------. ---------Address . Type of Building Size Lot.................... .....Sq. bet V Dwelling—No. of Bedrooms........ ..................................Expansion Attic ( ) Garbage Grinder 4) '_l Other,.—Type of- Building ............................ No. of of persons............................ Showers Cafeteria a ( ) Otherfixtures ................................. • ---------------------------------------------------- W Design Flow____ C_5-�__._._.•..............�.,� gallons per-per-sem per�day. Total daily flow.._....... -_.,..._ '�_. ............gallo�s. WSeptic Tank— id capacit __ allons Lengthl " ..... Width... _________. Diameter.............._ p De th...51----• .. x Disposal Trench�To..................... Width.................... Total Length.................... Total leaching area....................sq. ft.' Seepage Pit-'No._ ......... Diameter/Q'_ _.... Depth below inlet._��_. c--w . 'T0 hing area /�?2�sq. ft. Z Other Distribution#+box (4..-) Dosing tank Percolation Test Result a Performed .. .. ...._ .--.?--....�._�'Z Date./G._ .......................... atf minutes per inch Depth of Test Pit.................... Depth to ground water.....................Test Pit No 1_ _. GT4 Test Pit No'. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descrip r�.of Soil ( - w •••.. ---=-----/J........ 4 + V.... _ _ --------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable._______-.__________________________........................................................... ..----------•---:.............................-.........................-.....................................................................................................--------•--••-••--•---•---- Agreement t y The undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with the provisions of TITIZ 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. ied.__.... ----------------•----------:---------• ---L -w--/---!-�-t--.-.----------------•---- � � y '�iAPPlication Approved By _.._.. --------- --- , ! Date .' APPlication Disapproved fl&r�the following reasons-.......................................------•---------------------------------•-. -----...--•-•---_:....._. ............................................... .. ........... ............................... Permit No............ .. Issued 7rDate ................................ Date } 1) THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH �.,.�LA.�`?�i''?�!...............OF....... .. (9rdifirate of Toutpliaurr;-` THI IS C TIFY, That the Individual Sewage Disposal System;constructed ( �"j or Repaired ( ) by...".. .... .................................. ---------.. ._•_.... .. ......................... at........... . ._......y�.i�.............. . Q all �� .. =... has been installed in accordance with the provisions of f,The State Sanitary Code as deys�r' ed in the application for Disposal Works Construction Permit N _: .f � ................. da.ted_-..__l: _._(-_-__................... THE ISSUANCE OVTHIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM'%.Wi LL FUNCTION SATISFACTORY.' DATE................................................................................. Ins,,pector,...-= ..........................................................--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q .. .........................OF..........:.F'L/...lGam..=.!r.�r..........._.............................. �'�.'*� No....................._.... FEE. •-........ je�d....: union rrutit Permission is hereby gra ' -, to Constr` ) o e air. In Sevt age Vpb l Sy at Street q► as shown on the application for Disposal Works Construction Pe N ..._ ___ __:_ " Dated...1"�__1............................ - ............. 1 ' Boar of Health �q pl DATE.._.. ................................................. 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