HomeMy WebLinkAbout0292 OLD MILL ROAD - Health E
Old Mill Road
46-084ons Mills
No. Fee V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0(pplication for Migool *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. _1 194�� � d ner's Name Address and Tel.No.
J I ,ejt"1C)Z
Assessor's Map/Parcel 5'1
Installer's Name,Address,anTel.No � --� Designer's Name,Address and Tel.No.
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 s gallons per day. Calculated daily flow 9,5 d gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic-Tank /o 0o Type of S.A.S. 1isd C_uA, e— i STN2
Description of Soil 4/
I
Nature of Repairs or Alterations(Answer when 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 he Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been's u B of Health.
Signed � ,� Date
Application Approved by 101
�� e Date ( (�Application Disapproved or the following s
Permit No. Date Issued
No. ��(cc((r/// Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered i__computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Z[pprication for Oigaal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade a Abandon( ) O Complete System El Individual Components
Location Address or Lot No. .1 6 /�. ' ner's Name Address and Tel.No.
Assessor's Map/Parcel Qy� 0 $y
Installer's Name,Address,and�l.No„��` U [ Designer's Name,Address and Tel.No. T
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 33d gallons.
Plan Date Number of sheets Revision Date
Title 11
Size of Septic Tank /aao Type of S.A.S. "33d Cu AX, e- CvjZ S�irvQ
Description of Soil .rr 4 aA0
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
A
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 he Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been 's t i B of Health. n
Signed 41 Date
Application Approved by �/ v Date
Application Disapproved for the following reasons
i
s Permit No. " Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Se age Disposal System Constructed( )Repaired ( ) Upgraded
Abandoned( )by d A H X
at 7 Z ()Id 7�// Ref "V12, �/fzJ Z l •2 -has been onstructed in accordance
with the provisions of Title 5 and the for D 7'Disposal System Construction Permit No ed S O/
I
Installer Designer
The issuance of s pe f t'shall not be construed as a guarantee that the syste ;}11 fu i s design n.
Date ',/��/D/ Inspector V��XlL�, C. 7/�,vt.�-,�
D
-- --- ----------- ----------
No. l� Fee ---�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH•DIVISION - BARNSTABLE., MASSACHUSETTS
Ii.5po0ar *p5tem Con.5truction Permit
Permission is hereby g e, t Cons ct( )Rep 'r Upgrade , ) .•bandon( ) ' ->
System located at ,--,�- M ��
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/mustbe completed within three years of the date of this permi.
Date: Approved by / 4�
l/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
ste Septic S p y ms Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR DISPOSAL r
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated �` / , concerning the
property located at 0r3 meets all of the
following criteria:
This failed system is connected to a residential dwelling only. Th
ere re are n� y o 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]
J 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) 116
B) G.W. Elevation ?(o +the MAX. High G.W. Adjustment . _
DIFFERENCE BETWEEN an a>
SIGNED : _01 DATE: Q
[Please Sketc ;posed plan of system on bacl ].
(NOTICE
Based upon the above information, a repair permit will be issued for 3 bedrooms maximum. No
additional bedrooms are authorized in.the future without engineered septic system plans.
E
q:health folder:cert
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THE COMMONWEALTH OF MASSACHUSETTS !l
BOARD OF EALTH
Ab l .......�. ...... OF........... �--. .------............................................
Appliration -for Uiopoottl Works Towitrurtion Vrrntit
y Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
r Location-Address or It No. '
Address
Installer Address
QType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...4-------------------------------------Expansion Attic Garbage Grinder kiPeT
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 i uid capacity '___gallons • ength________________ Width................ Diameter................ Depth....-__-_--.---.
Disposal T cti °No..................... Width.__ - T tal Length..........; . ------ Total leaching axra....................sq. ft.
y
Seepage it No..__/`_____----__- Diameter. ./ Deflbelow inTe1"... .......... Total leaching area--.-.----_-----_.sq. ft.
Z Other.Distribution box ( ) Do tng tank
aPercolation Test Results Performed by.......................................................................... Date.....................
a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.-.-- --------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............---.-_-----.
�. -'_. y ...-
O of Soil ,2: �` '/ I' ----------
Description �1'�..... . �z... ----
W ---------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- --
U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------.
--------••-•-----------•----------------•--•----------••--•---•---••-------------------------------•----------- ---•----------------------
-------------•--•----•---------------•------------------------
Agreement: I -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss d.by the board of he t
Da te
Application.Approved By................. ... ... - ------- ----- --- - ----
Date
Application Disapproved for the following reasons-....................................................... ...-------------------.....--•---•-••-•--•-••..........
---•---------------------------------------------------------------•-----------------•----•--------------------•-----------......-----•-----------.....------...._._.....--------------------------•-•--
Date
Permit No......................................................... Issued..nZ-°�1®_7.:7...............
Date
J6 -
No ,�i1
:_ Fims..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF,-HEALTH
Appliratiutt -fur Rapooal Workii Tonstrurtimtt Vrrul t
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-----------------------------------•---....-••-------•--•--•---•-- ---•-•------•-••........
------------
••-••-•--•-•-------•••-•---
Location.Address or Lot No. /
".- / -- C
-------------
= ----------------------------•----------------- ........ ...t.................••.•.....•-•••..........-••---•-----�......-••---••---•-•-•-•--
Owner Address
W
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms------- ........................Expansion Attic (-'G) Garbage Grinder (r>C)'
"1 Other—Type of Building ---------------------------- No. of persons-------------------.......•_ Showers Cafeteria
a' Other fixtures ---------------- ----------------
W Design Flow-------- 5,7,1'"•.......J`r!�----------gallons per person per day. Total daily flow-----------------------=_'_-_---.--.--._...__..gallons.
W Septic Tank-Li I'
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 ( ) / %-
a Percolation Test Results nmPerformed by------.................."__1_______-___--_______-____-_____•--------•- Date._.........._._ ..//)Test Pit No. 1---------------- utes per inch Depth of Test Pit-------------------- Depth to around water----- ,._-..___.
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-••---------------- -----------•--------•--------------•--••--.............__...-----••--•-•-••-••........!--•-----------------------------------------• ---
O Description of Soil--- ----- /-•------ fj-�f /-- r�
V ~- ......- --------------------••--F••-•-----••----------•- --- --:f......----...._- ..._..._._.._...-----------==-------- -
W
V 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 Article XI 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.........................' J ".l S
- -
Date
Application Approved By----------- :do_......
Date
Application Disapproved for the following reasons:---•-------•--•-•-•-•---•------------------------------- -----------------------•----•-•----------------------
•.........---•...........................•-•...-------- -••-------------•---••-------•......-•••----•-•-
i � — w � � Date
Permit No. Issued................._.....------ �----.....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................... OF............................... ..................................................
Trrtifiratr of 101puutpliaurr
T IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (G) o/aired ( )
f----• -----.. % G/il ��� �, f ✓l�L .11 � `__ .._._......
Installer
... -----------------•----------•----•------- ---------- --•-----.----- ._.........----....---------••-------._...........••--•...._--.••••-
has been installed in accordance with the provisions of Article XI_of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..._------_.5__.v_.!�______-_-_ dated..... !_-_. _. _}__�_.. ....... _.
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
7------------------------------ Inspector.....
THE COMMONWEALTH OF MASSACHUSETTS
1 BOARD OF/.H) EALTH
++ .........r�`. � ...............OF._........�........ .............-----------------------....--- '
No........
_.� FEEZ.Z --
R-tiVa ial Nork,6 Ton'titrurtion V-r-rmit
Permission is herebyranted� :Z f' - ...............................................................
to Construct ( ) or Repair ( )ran,/Individu 1 °Sew.age�Disposal.,System+/ "
at No:: e� .iif ---d••C--•=------..... ....._ �.... tf //'I-�''r`"-----
U r ��l Street
as shown on the application for Disposal Works Construction Permit,,No.............!�:Z Dated tl--- —
-- ......
lzz
2 Boa eal Board of Hth
7-----------•-------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r TO OF BARNSTABLE ✓
LOCATION Old ,/�U - SEWAGE # JIVIo
1
VILLAGE 4A4' ASSESSOR'S MAP & LOT G ��
INSTALLER'S NAME&PHONE NO. 41A,'Ts y2i-6-1y5-
Zac
SEPTIC TANK CAPACnY aa�^ O -�/�-
LEACHING FACILITY: (type) J if ec ire PrS (size) %D X�9�
NO.OF BEDROOMS 3 BUILDER OR OWNER r-k
PERMITDATE: `S� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 7� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 15.D Feet
Edge of Wetland and Leaching Facility.(If any wetlands exist
within 300 feet leaching i 'ty _ &A Feet
Furnished by
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