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HomeMy WebLinkAbout0344 OST.-W.BARN. RD - Health 3�f H os+ - w. (3pn-n .2d Vharsroos rn1119 i NC........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH _._ .. I`'----OF.......... Appliration for 3!ivasal Works Zomuurtion Vamit Application is hereby made for a Permit to Construct fooror Repair (1!) an Individual Sewage Disposal System at: —�- _/ ® ' CFJrol-er e � 9- 40s/er✓i ll�P �qt.�s/sb���vf ------------------------{' ------...------------------------------•. ......................------------------------------------------------- yy Lot N�3 -- --- --------i- --- a !f n-Ad dress r✓ /�o r ............. ......✓00 ............................. ................. - --- /-! --------•--------f- �9/ '-'------0Owe i Address -----•-•------ ............. k/?G -------------- �iv/�/✓ Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms__________________ ___________ __ Expansion Attic ( ) Garbage Grinder ( ) �-+ .-a p-, Other—Type of Building 5� ..�r� �e� No. of persons..........I________________ Showers ( ) — Cafeteria ( ) 0.' Other fixtures -•----------------------------- -- -------------------------------------------------------- Design Flow............. -_� _.._..._.__._gallons per person per day. Total daily flow._............20--__-_____-.----. Wga P P P Y Y ....gallons. WSeptic Tank—Liquid capacitv1�_-gallons Length................ Width--------.------- Diameter---------------- Depth.__.---_--_---- x Disposal Trench—No_____________________ Width-------------------- Total Length.................... Total leaching area-------.------------sq. ft. Seepage Pit No...-10_4©------ Diameter.................... Depth below inlet.................... Total leaching area.--.-.-_-_.__---Sq. It. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY------___............................................................. Date---------------------------------------- 04 ,_l Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water-....__------------- G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_.-.-.-_-_-------_-. -. Ix ------------------------------------------------------------------------------------------------------------------------------------------------------------ 0 Des-- -------------------- - ription of Soil -- --------------------------------------_--------------------------------------------------------------------------- x . � --------------- x ------------------------- ------------------------------------------------ ------------------------------------------------------------------------------------------ ................................. U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------ Agrtement: 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 b by the board of health. Signed.... ...•..... .... ............-- ......--C ...---........ Application Approved BY----------- / -------Date -------- --------------------------------------------------------- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- .............•-----•---•-•------------------------------------------------------•------------------------•-----------------------.-•-------...----•---...------------------------•---•-•--------------- Date PermitNo.-----•.f`�........................................ Issued........... .. 9....75�--------------..... Date f :.... .. THE COMMONWEALTH OF MASSACH SETTS EOARD OF HEAL H ------- ----- -- ----------- Appliratinn -for 1:3 i5 oiial A cation is hereby made for a Permit to Constru or,Repair an Individual Sewage Disposal System at: ` APT $ -4���-�,//�-G ,:� ��./i ... --------- -------------- --------- ------------------------------------------------------------------- �r Lf catianp-Address K ,/ or Lott No .K1�4!�h .........................a` r �. � idl.�l��!••s I! Ow er Address a 7--------------- U�'` G-----_-------_--------- Installer Address UType of Building Size Lot___________________________Sq. feet Dwelling—No. of Bedrooms_______________ - Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ____ __/!44' No. of pel-I- ---..... ................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- -- W Cesign Flow............ .lAr:.............gallons per person per day. Total daily flow------------- WSeptic T trik—Liquid capacit✓ -__gallons Length---------------- Width................ Diameter................ Depth-. _-----.--. . x Disposal Trench''.=No ` Width____________________ Total Length-------------------- Total leaching area........_----------- q. ft. 3 Seepage Pit No._100?------- Diameter____________________ Depth below inlet.................... Total leaching area------------------Sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY---------------------- Date........................................ a Test Pit No. 1--------------__minutes per inch. Depth of Test Pit.................... Depth to ground water.--.-.._---.---.--.--._. �14 Test Pit No. 2-----------------minutes per inch Depth of Test Pit____________________ Depth to ground water-_._-.--_------ .. 9 ---------------------------------------•••••••-------••-•---...---•--------•--------------•----------------.............-••••--••--.....•................ 0 Description of Soil------------_----- x � W VNature 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`bee sue by the board of health. tgned-'--- Date Application Approved BY ----------------------------------- Date Application Disapproved for the following reasons-------------------•-----•-----•----------------•--- z.::<,....-•-•-•-••----•.........................-•------ ..........-••--------•..._......--•---••-•---•-------------------------••----•------•--•-•---... Date PermitNo., ......+................................. Issued--................................ _ ?.ate��� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................O F......0�7 �ST61*�« Trrtif iratr of Tom fianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System consfructed� ) or Repaired ( ) by.................�'��� . -------------------•-------------------- Z ,g Installer �'f ;ld1 ft - •------- ------------ has been installed in accordance with the provisions o€ Article,X1, of T e State anitary �de 4416e's4itA-in the application for Disposal WorksrConstruction Permit No:-................_---------------------- dated--------------------------:..................... THE ISSUANCE OF THIS �CERTIFECATE SHALL/401'9E CONSTRUED AS A&U B71fE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATI .................................................. Inspector------ --•----------- -- ---------••............................ �� iy i�tKyy.��i.. �`�T•�; �f ma's£ �..A _ THE COMMONWEALTH OF MASSACHUSETTS BOARDSQ,,1F H,EAL�T��--1I «: " L�.d�+'...........OF...............:................................................................... 'CS N-O.. - X.r .,i"ti{'-2 FEE. .... �... Dig otitt1 Nor ,, LIT" OW on �rrmit W Permissionis hereby granted----------------.............................................................................................................................. to Construct ( ) or Repairi,6 an Ind' i u wjj2p is osal yst �, 19 a�E. © ' ' , at No ......................... ----------•---- ---------------------- , r ` ' � Stxeefi. �- as sl own on the application for Disposal-'Works Construction Permit No..................... Dat �,.. ........ -- - --- - -•--•--•-- .......................... -------•---- .+7 / Board of th DATE. / " / FORM 1255 HOBBS & WARREN. INC, PUBLISHERS `- TOWN OF BARNSTABLE LOCATION Nfe VILLAGE CJsfEr✓�l�r ASSESSOR'S MAP &LOT/V-09,L INSTALLER'S NAME&PHONE NO. 117—0 3 yY ), SEPTIC TANK CAPACITY /S00 641 LEACHING FACILITY: (type) 51 )W,4xl (size) 3 s X 9 NO.OF BEDROOMS .3 BUILDER OR OWNER PERMTTDATE: 98 COMPLIANCE DATE: Separation Distance Between the: 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 L �s T cv,�J�r��t'�yl� '� - � � ,^. C ' ;�, .. e w � .. ..1 ..�.e _ 6�C� .. 9 _ � _ . . � m ' ,� " . y � �_ r 6 .� .� •, 4 . . . r, No. � Feec /� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS ZippYication for Migpogaf *pgtem Comaruction Vermtt Application for a Permit to Construct(repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.3441 0S1-;y/i!h' L,b-41w` Owner's Name,Address and Tel.No. y2Q' 2 Osrr-r✓;//-e- IVOJ4 A & // ✓.-, Assessor's Map/Parcel / ,cg -a-P� , / �i ) Glf� 3 v/ Installer's Name,Address,and Tel.No. q77—03 49 Designer's Name,Address and Tel.No. ✓asle_ply 0-0 13141- 0S $/ G oils it S!4/'L'Ji= Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /fD0 Type of S.A.S. Description of Soil S's."el Nature of Repairs or Alterations(Answer when applicable) 611 _a Xis h _ uii li %ti tAsll /sod Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by r Date Z_ Application Disapproved for the following reasons Permit No. "— TOWN OF BARNSTABLE i ��/ i LOCATION .�9Y OsrE�Yi%�F /•j or I& (SEWAGE# .I8 Lo T .V _ s MAP _ ASS ESSOR'S R , r ILLAGE f�sfrr✓ � ASS / n . `INSTALLER'S NAME&PHONE NO. 77—0 3 4�9 Jos��� �c �rrO s :$EPTIC.TANK CAPACITY �/ hl�x�ni/Fd'S .(size) ;I:EACHING FACILITY: (type) NO.OF BE 3 . <>''.B. ILDER OR OWNER r PERMTTDATE: /� 98 COMPLIANCE DATE:_—y .; Separation Distance Between the: Feet i~ Iviaaiinum Adjusted Groundwater Table and Bottom of Leaching Facility>Private Water Supply Welland Leaching.Facility (If any wells exist Feet on site or within 200 feet of leaching:facility) Edge of Wetland and Leaching Facility(Ifany wetlands exist Feet within 300 feet of leaching facility) .<Furnished by 1 , j ::..� J�y�.���•��.� 1ST •�' . i a NO. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Migpogar *pgtem Congtruction Permit Application for a Permit to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 34Y .§fF-r1/i/11= W, Owner's Name,Address and Tel.No. 0srr-rv1'1/� /�/o�u 6i !3i_// ✓r. Assessor's Map/Parcel ` t l.. / 7 4 3 op i/l= Lr/, sir 4r, Installer's Name,Address,and Tel.No. 4Y 77 Designer's Name,Address and Tel.No. J14k$91.5 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /f0U Type of S.A.S. Description of Soil Nature of Repairs or Alterations An wer when i 1 i'/ F i h p t ( appl cab e) / .X a _ Y) Date last inspected: Agreement: 1 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 issued by this Board of Health. Signed Date. Application Approved by _ Dai Application Disapproved nor he following reasons ed --Permit No. "— --------_— DateIssti -- i --"` - -- --- '( THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(4—)-Repaired ( )Upgraded( ) Abandoned( )by a e rv-v at I5'y Osra.-ytMa 144 vA4. /1 7 Osr.--yy///,e has been constructed in accordance with the provisions of Title 5-and the for Disposal System Construction Permit No. & dated Installer Jos,-p/i V. Designer ,/asa A D.e� 13,w nL,a_s The issuance of this pe t shall not be cot1strued as a guarantee that the system will function as designed. Date �. Inspector , ----_✓---�6------------- Mir ,�r ------------- - — No. �J 1/ /� p �,�/ — d�S Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogar *pgtem Congtruction Permit ' Permission is hereby granted to Construct( 4-),Repair( )Upgrade( )Abando ( ) System located at .3 5'y O.sr1:/-I/i%/� U/i2� 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. e it. Date: �� Approved bye4 �f% � i a i 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CE RTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, ,/0J'--P4 D' SN""OS , hereby certify that the application for disposal works construction permit signed by me dated 8 , concerning the property located at Gz/ / meets all of the following criteria: i There are no wetlands located within 100 feet of the proposed leaching facility e are no private wells within 150 feet of the proposed septic system Z1'hnh$ex'e p is no increase in now and/or change in use proposed There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will bpi be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) fly B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: /—G 7 g LICENSED SEPTIC SYSTEM 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). q:health folder:cert IL <� Bic oo (��� J r• o • - s doh ���� �rr� CIF " s�� 117 Gh s P Y ��ximi rs all !9✓'av✓� ohm Lw i . . TOWN OF BARNSTABLE /p� LOCATION �yy OSr��Yi//F f1-&r#. 1-*11i ' �P�EWAGE #_ I ' VILLAGE ASSESSOR'S MAP&LOT 9 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /S 00 (o LEACHING FACILITY: (type) S� lylwxr (size) NO.OF BEDROOMS S BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 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 faci 'ty) Furnished by Ve2Z� 53 0 1 1