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HomeMy WebLinkAbout0021 ROSS LANE - Health ROSS LANE, LOT 16, M. MILLS A=123-034 TOWN OF BARNSTABLEjL LOCATION Z6�-//,i SEWAGE # 9 7 i _X7 VILLAGE, ✓1S,/�i��5 ASSESSOR'S MAP & LOT 1 INSTALLER'S NAME&PHONE NO: SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i �lu.«.(�5 (size)--G��� NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: I r X 7 _ �_ 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 i, p 3AA 1 A C V'3� a. A osti-'� 9 1 9 1 .. z A� -wl A Ar -N6 6 A W e 61) - 47' BE 43► F _ 39' i_D —E — F 0 TOWN OF BAiZNSTABLE LOCATION �ezl zi4e SEWAGE # 9 F VILLAGE; 25 ,��5 ASSESSOR'S MAP& LOT INSTALLER'S NAME dt PHONE NO. SEPTIC TANK CAPACITY /5 00 LEACHING FACILITY: (type) _Ae�4 ..e 16 (size) 'S W/ NO.'.0F BEDROOMS_ ,/� BUII- ER OR OWNER di22il& wwa-. PERMIT DATE: - 11 _ � COMPLIANCE DATE:T �� Sepa[ationDistance Between the: ! Maximim Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist orisite.or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Aiwa 300 feet of leaching facility) Feet r< Furhistied by i. ,Sf - A 9 Ah - 39 ,oh - fifl 8 0 d a b J AV z ,`o� - dY 1 NO. THE COMMONWEALTH OF MASSACHUSETTS PEE BOARD OF HEALTH_ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) -- ❑Complete System ❑Individual Components Location f, 0,80y- 2`Ly Owners Name /"jrJ T' A [f(�Ll mil/�J S �'`�1C( D 2.0 Ol Ma /Pa/cl# ` QGldres`� Lot# Telephone q Installer~ t ! Designer's me 257 P�,I P� tee. MUM&ifh O f re ss o�5qo Address ISO 5yC3--A�4"s 3 :5 G -Z iq—fe-/ Telephone A Telephone#i Type of Building: kt5 Lot Size "/ 110 Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. required) gpd Calculated design flow 3 a gpd Design flow provided gpd Plan: Date Z 't-& , Number of sheets Revision Date Title /g4-/fy-< U. — Description of Soil(s) ��� oe k4-,✓ Soil Evaluator Form No. Name of Soil Evaluator O/s�� Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agr s to install he above escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a s n to I e the system in operation until a Certificate of Compliance has been issued by th Board of Health. Signed e e7 issu o J FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 �. l/n No. , '" `'' �HE COMMONWEALTH OF MASSACHUSETTS EE / a BOARD OF HEALTH ` _ OF a-L-r APPLICATIONNJOR DISPOSAL SYSTEM CONSTRUC IT ON PERMIT Application for a Permit to Construct ( Re/pair ( ) Upgrade ( ) Abandon ( ) -- ❑Complete System ❑Individual Components LoT /li �SS .CRAo' 14/r.//h h4p*eJ �. Location . ' Po eoX, Owner's Name (� 122y ��,,,�tiv,�� wl4 D2GoL 'Map/Parcel � �icl# dress�� 7/- � Lot# Telephone# rA,,v tie q, 4 s2/ '* "iHl Installer Xme Designer's`�me 7 '# A dress Q�,S'yd Address fTelephone# Telephone# ti + Type of Building: /^L S;e4 cGg... Lot Size "f 1-029 Sq.feet Dwelling—No.of Bedrooms _� ? Garbage Grinder ( ) i Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) '3 3o gpd Calculated design flow`''�3 o gpd Design flow provided 33(o gpd Plan: Date Z 'LG Number of sheets i 'a. _� h Revision Date 3 Title - 5 i �� �✓44.L- a�t�5�. a� 'L©T /(. �1 S .�r.JE� - 1 Description of Soil(s) 5Lf /�/"'��✓ Soil Evaluator Form No. Name of Soil Evaluator O/ Date of Evaluation /- 9-7 DESCRIPTION OF REPAIRS OR ALTERATIONS { The undersigned ag two inns�t 311t he above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a s nee of to la•-e the system in operation until a Certificate of Compliance has been issued by th Board of Health. / Z�. 8 Signed A Date a. An 14 FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 + i No. THE COMMONWEALTH OF MASSACHUSETTS FEE Gr(nS BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: 0 Stf- 6) &4,,L at 2 RoSS (-1 e, -- Met r!s&o s i��1 l 1 s for 14 has been installed,in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.97-I2: dated Z - 2 77-•9 _. Approved Design Flow (gpd) Installer, .- Designer: Inspector Date o The issuance of this certificate shall not be construed as a guarant a that the system will function as designed. f FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 t1 d O No. THE OMMO WE LTH OF MASSACHUSETTS FEE 413%ll'k-OARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby gr aate .o C trust R pairAl��Upgr�ade ( ) Abandon � ) an individual sewagedisposal system at �� M -��`` Y A 1 a as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date Board of Health i FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS- BOSTON Town of Barnstable P# Department of Health,Safety,and Environmental Services �,t,e,q� Public Health Division Date 7 7 367 Main Street,Hyannis MA 02601 MAFA S uaxarear�, 2 ,, 5 Date Scheduled ) _ 7. �-_ '7 F; l � Time �8 A M Fee Pd. P� Soil Suitability.Assessment for Sewage Disposal Performed By: Witnessed 13y: 5j►�-4 -1)vNAJ IMP LO ATIbN & GENEk", Il'�1 O lVIA 'tON ® 3 Lt . � c.A. y/arM)L-,Tts tJ pxt"� S Location Address L ']� Owner's Name r, - • o"L Address E-} AN N l(;,,A-A L-07 16 Pr3'L.k 7 Pdt 27 Assessor's Map/Parcel: )2313j Engineer's Name->pW N Chft E-P&IONJA r NEW CONSTRUCTION JL/ 6 REPAIR Telephone# 3 2 4 I LI) Land Use V,07t-�N'r Slopes(%) 0-5 Surface Stones Distances from: Open Water Body Tft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line Y - ft Other �� ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Z©SS LAN i �. Z C, ,ao hT 16 o LLL r lot .I HZ S Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater N ,4 Iv8 6-a vN�Ajz-tip METE NA'ICYC N D SEA i �.Hi t3[ 'AT ;`t~Al l Method Used: /^ Depth Observed standing in obs.hole: �,�in. Depth to soil mottles: _in. Depth to,;ceping from side of om.hole: ' m. Groundwater Adiustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PE ...COLATION TEST Date Trote Observation Hole# —71+ 1 Time at 9" r/ Depth of Perc e, Li O Time at 6" O r' Start Pre-soak Time Q � �^� h O() Time(9"-6") End Pre-soak Rate Min./Inch G.2 '''''�``►�I N t Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) /V Original: Public Health Division Observation Hole Data To Be Completed on Back--,j Copy: Applicant DEED OBSERV k ON HOLE LOG Hole.. .. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % p- & A SL 7.5 Tip-3/2 G - 3Z 3 LS ioY��/s LO sc 79 -13 - ; DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % 5•4 A& DEEP OBSERVATIONIUI.E LOO Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % ..... ..... ........ XXXXXXI. DEEP OBSERVATI01'�1 HOLE LO Hole# . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % DEEP OB ERVATIOI'd OL E LOG Hale Depth from Soil Horizon Soil Texture Soii Color i Soil I Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. %Graych 4 7;:. 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