HomeMy WebLinkAbout0216 CHURCH STREET - Health n
216 CHURCH STREET
West Barnstable
A= 153 - 022
_l
Town of Barnstable
�•++� Regulatory Services
Thomas F. Geiler,Director
s Public Health Division
639 `- Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
-Office: 508-8622- 44 Fax:?508-7 0-6304 ,
Date: w;,Z!72,oz° Sewage Permit#Q4�' �� Assessor's Map/Parcel
Installer&Designer Certification Form
Designer: ���rf"'Z L'N " ' Installer: PAJVCk 1Z YJ
Address: AX 10, Address: FD : QX 7 7S—
jai sf
On �� l �� '/����(�� was issued a permit to install a
(date) (installer)
septic system at 414 44 based on a design drawn by
(address)
�cJ��3�L �Jr.�✓-��k�"71 dated 4Q r �&o
' (designer)
v I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State &Local Regulations. Plan revision or
certified as--built by d- ign r to follow. Stripout(if required)was inspected and the soils
e ford-s' tisfact ry. 1H or
`gy
�sQ TEP ENCE cy�
U IVO, tt�
(Install ature NAYS, ;
....y 4� �;, c�� o
,. . (Designers igna )"e ` (Affix Desi M p Here)-
PLEASE RETURN TO BARNSTABLE.PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice formsWesignercertification form.doc
�j TOWN OF BARNSTABLE LOCATION
roC l(o C �/,�/�}� S7�PF T SEWAGE # -4%1
VILLAGEJIV ESrt"' A�2_ti1�C14�I nF ASSESSOR'S MAP & LOT 0 —
INSTALLER'S NAME&PHONE NO. IV
SEPTIC TANK CAPACITY _ I,500
LEACHING FACILITY: (type) S (size) C r��lle►�
F
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: o
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 fi•' A: l Feet
Furnished by ��
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COMMONWEALTH OF MASSACHUSETTS
Aoard of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM C ST UCTION PERMIT
Application for a Permit to Construct Repair( U trade(�/lAbandon otn Iete s stem O Individual Components,
Ph O p' O pg. O - p y p
Locato Owner's Nam
Map/Parcel# Address j
__.
L.P.W. �1 � Telephone#
Installer's Nam Designer's Name j2 En
.Address S1 Address
Telephone# J ` Telephon
Type.of Building Lot size..... sq.ft.
Dwelling:-No.of Bedrooms. .. _. Garbage grinder. { )
Otller-Type of Building . . .. .. No,of persons__ Showers ( ),,Cafeteria
Other.Fixtures
Design Flow(min.re uired) L��_gpil Calci9lated.design flow Design flow prow d S gpd
Plan;' Date Number of sheets_ Revision;Date
Title �17i7` �
Desciption:oi Soi1(s).. .. (.
Soil Evaluator Form Na Name of.Soil EvahiatoDate of Evaluation 9 -
6
Name 3 --
DESCRIPTION OF REPAIRS ORAITERATIONS
The.undersigned agrees to install he above described Individual Sewage;Disposal System;in accordance with the provisions of TITLE 51 and
_,.
further agrees Ito,not ice th� temt' operation until a Certificate of Compliance has been issued by the.Board of Health.J �j
Signed �"o�•� ' ''r Date
Insctons... �. . .
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All
NZA0 iC{
t(� F. r t + FEE
Board of Health MA.
APPLICATION .FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( )'Repair( Upgiade(if) Abandon( - 0 Complete•System O Individual Components
Location_1�1 C�-f C l7 - ,r . O.wneCsNamc oArv-— ". 1,#W�) i
Map/Parcel#t# ! �. kfv R CA.n Address
_. ( �� 4✓ � t7 Sr M/
La _
21C(� M It
Installer's Name-M ; - Designer"s Name\
Address xr 9 9 Address
Telephbrie# Telephone# ;3 1 4?0
` Type of Building A Size sq.ft,
Dwelling-No.;of Bedrooms: ,. Garbage grinder
Ocher-Type of Building ( )_ g No,of persons Showers ( )::,Cafeteria.
Qther Fixtures
Design Flow(min.re aired) J gpd Calculated design flow Deesign flow provided T gpd
Plait: 'Date ."! "r t 4 Number of sheets Revision Date 10 ll // .r} .
Title 'Re) �3���7._� ���.a n 1`_1 . . .
Desci-iptionofSoii(s)'
.. Soil Evaluator Form No. Narne of Soil Evaluator �,.v Date of Evaluation._ C' ' 7-1,-1`�
.,
7 K
DESCRIPTION OF REPAIRS ORAI.TEMTIONS �J- L �. •'. r` E
The undersigned agrees to install the above described Individual Sewage;Disposal.S tem.in accordance_witli.the provisions of TITLE 5.and
further agrees to not t the tem}�goperation until a Certificate of Compliance has been issued by the Board of Health.
..
j : Signed �• Date M
Ins,.coons. r
FEE
COMMONWEALTH OF MASSACHUSETTS
Board o f Health; t 1 MA. t'
5 r
CERTIFICATE Of COMPLIANCE
Description:of Work: Elludividual:Component.(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System;. Constructed ( ):,Repaired ( ),Upgraded (,o)�Abandoned ( ).
by: '' 'x %01V�;A_ i�I � . . " - ; _fit' l_ I. C 1t1 F ,L_
. :-
has been installed in a cordance with the c0 sio'i f 31.0 CMR 15.00 (Title 5) arld the approved design plans/as-built plans:relating to.
1
• application;No. 01 dated { � � . Approved Design Flow -(gpd)
Installer
R= ,/i
Designers Llf /? Inspector: c 4V C 1 Date.:
The issuance of this;permit shall not be construed as a guarantee that the system.will function as designed.
No..001 1 [ ( 0 FEE /
COMMONWEALTH Of MASSACHUSETTS
Board of Heciltft, MA.
.DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( } Repair( ). Upgrade( Abandon( ) an individual,sewage disposal.system
at . C__12j6::::1 ( ._. l/"112,11.4 _�T ) as describe&in the application for
Disposal System Conw uction Permit No?_019-qj 0 ,dated 12(3!f Z t°�
. ,
Y
Provided: Constructicn shall be completed within three years of the.date of this pet mit. All-local conditions n ust:be met.
Form 1255 Rev.5/96;A.M.SulRin Co,ChrtleSlown,.MA Datel �1 fr!' Board of Health
k.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application for Disposal Vorko Tonstradiun Famit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
....c�?l� -..... •-• . .........F...............•...-- = '-�� ,-------- - -- -.:...........-•--••---
- Location- ddress _-_Lot No.
Q ....���rz._•-----G U ....... ............ -- �:...: ..._......_..--
___. --
Owner Address
� Installer Address
d Type of Building Size Lot-.I, _!l '1_-..—_Sq. feet
Dwelling—No. of Bedrooms...............3........................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—T e yp of Building -__- •_.S ........ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures ------------------ ---------------------•-----•- ..
W Design Flow.................. .............gallons per person per day. Total daily flow............ �.G..._._............gallons.
WSeptic-Tank—Liquid 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water_____-_______---___ -_
GT., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ----------------------------------------------•----------------...........---------------•----------.........................................................
0 Description of Soil....... . !!1.�3'�11--- ._ ..S---.Oaf--
cx, .u� ---------------------
x
U Nature of Repairs or Alterations—Answer when applicable Je_a!re�,ll✓O
Agreement: 4
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as een issu by4e board of health.
Si ned ------- -----. --
�_. to
ApplicationApproved By ........ ------- �� � ............................. .......--------................... -- --- --- -..... .u..---------
e
Application Disapproved for the following reasons- .................................................... ..................
........................................
------- -- .------
----------------..................------------------------------------------------------------------------------------------- -------------------- -------------------------------------------------- ----------------------- -------- ---
Dat
Permit No.
'--�J..�...-------..�J��...0.....-----.............- Issued ................7--�7�=----J.'
v-----------------
4
No.--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
TOWN OF BARNSTABLE..
Appliration for Disposal Works Tonstrnr#inn 11nmit
Application is hereby made for a Permit to Construct ( ) or Repair (<) an Individual Sewage Disposal
System at: °
R
Loc or Lot No.
ation- ddress �
.............
--- -----•----- / �5 � .......................i S?
Owner Address
7l j GGG4�!:� J._ r�!? s15/��14
Installer Address
Type of Building Size Lot_.� :-t Sq. feet
�. Dwelling—No. of Bedrooms..............3...._ .________.Expansion Attic ( ) Garbage Grinder ( )
Other—T e of BuildinS--------------- No. of persons............................ Showers — Cafeteria
04 Other fixtures -------------------------------• -
W Design Flow..................... --------------gallons per person per day. Total daily flow.._.__._____4�G•--_---•--_.......gallons.
WSeptic Tank—Liquid capacity&k1gallons 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 ( )
Percolation Test Results Performed bY................................................................._........ Date•--------------------------------------
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2--------_.......minutes per inch Depth of Test Pit____________________ Depth to ground water........................
a •-------------------------------------------------------------------•--...-----••-----------•-------.........................................................
0 Description of Soil-----Q-- =-'-- GoAr?il-�5�=--- �,.4 -- �fS--- llll.
U ---••--•-•-•-•-•-••-•. al".ec-6........................................................................................................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable SZr�!P_o _� IQU/gc�lS•-,�yy / IG¢C_•-?p•.
-%ter �� _ ' !. n• � f
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance, as been issued by,the board of health.
Signed / il ... . .. ------
Z---- -................ ------- ---
te
Application Approved BY -----------------------� --- ------------ -[--71-P�i U----.......
Application Disapproved for the following reasons- ---------------------------------------------------------------------------_--------------------------------- ate------------------
--------------------------------------- ✓ h ------------------------------------------------------------------------ .......................-------------------f ----------------------------------------
Date
Permit No. - . ----------------- Issued .. .............. ------------------
te
THE COMMONWEALTH OF MASSACHUSETTS `
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate of Qlaraptinure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (y )
elc"Tt1----------- �^�`��^`------�NC------------------------------------------------------------------------------
----------------------------------------------
Installer
at - /........-.�'st/�/ 'r5/.......—--�` ------ ---------��C�.:... r ----------_-------------------------------_-.
has been installed in accordance with the provisions of TITLE 5-of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ---y ....3 3................. dated -.__7-/���_').................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE --/► �"' '... 1 Inspector ..... !•• ._..... ... ,.... - .--= _ ----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
g 303 TOWN OF BARNSTABLE
No.. FEE._.. - a. ..
Disposal Works Tnnstrudinn Prrutit
Permission is hereby granted........... !�G-D 77. �0A11% ` C'---=.............................._.._..........
to Construct ( ) or Repair (),,j an Individual Sewage Disposal System
-----------••--•- •... ...............
Street
as shown on the application for Disposal Works Construction Permit No....�a_3 0 . Dated.__ Gi_�--.
.............................0-._____............ ....._.....__....._...---..._.....
��G�_... Board of Health
DATE. ---
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FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS
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