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HomeMy WebLinkAbout0015 HEZEKIAH'S WAY - Health (2) os C)q-- C>b 1 tA), v r; f v N S M EAD KEEPING YOU ORGANIZED No. 12134 2-153LGN AINABLE FORS MIN.RECYCLED INITIATIVE CONTENT 10% Cemed Sourcing POST-CONSUMER NV wwwsfipmgrsm.org SR-01290 MADE IN USA GET CRGANIZED AT SMEAD.COM No. -- ---- ---- ---- B Fee-------- ---------..._ BOARD OF HEALTH TOWN OF BARNSTABLE Application-for Vell Con9truct ion A3ermit Application i hereby m ermit to Co sIt ct ( ), Alter ), or Repair ( )an individual-Well at: - Lo atio — Ad s Assessors Ma and Parcel 17 --------------------------------------------------------------------------------------- ----------- ---- - --- ---`�-/-------------------------------------- - wner O (+j Address / � � � � � -------------------- - - - - Installer — Dri- 4 Address Type of Building Dwelling--------------------------------------------------------------- Other - T e of uil n] � --- No. of Persons---------------------------------_____________ l.�Ci - - T e of Well--- ---- -------- ®--- - -- - Ca acit ------ Purpose — -- — — of Well------- --------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Privat ell Protec ' ation — The undersigned further agrees not to place the well in operation unti a i to m e h issued by the Board of Health. Signe --------- -— --- --- - -- date Application Approved By _-- --------------- date Application Disapproved for the following reasons —---------------------------—-----------------------------—--------------_---______________ ------------------------- - ----- - ------- - --- - -- --- - - - - --- date, /0 Permit No. ------ -- --- — Issued — -- — f - - — — ------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate ®f Compliance THIS IS T ERTIFY, tiv�idu�al 4�,1e11 Constructed ( ), Altered ( ), or Repaired ( ) bY-------0��-- M �Al( - /(7)------------------------ ------------------------------------------------------------------------ (y 01nsta �)4 has been installed in accorda '_y W-0 ,!?A ---------�?------—-—--------—---------——-- nce t ,( e with he provisions of the Town o��Barnstable Boar Heat nvate Well Protection 714 Regulation as described in the application for Well Construction Permit No.O _4_ -Dated---------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------— —-- —-- Inspector------------------------------------------------------------------------- :;�,-�... ,�. .,. ,•.� ..4 „s+.;� �-�•.�.. , -+rz. `.i; .l'' '- x, i"'•. ,... .s �iS..d7rx1°' t ;.�.Tt-, x.yv;r�w-7'.7'1�Yvi j.#:,.w'-�..<<..•'t.C.tws'�'c.t�nr,.w�... yJ h., �. ' 4-i'�1"`3s� �k �..r 1 (.;J � "rya O �„ .�+ls a3t �•,� Fee-------- ------------ BOARD OF HEALTH TOWN -- OF BARNSTABLE Application forVell Con5truct ion Permit Application i hereby m 1$o -ermit to Co struct ( ), Wter ), or Repair ( )an individual Well at: -Z - - -�L -- -- -- - --- — -- -- - Locatio — Ad s T Assessors Map and Parcel ------------- IA ----------------------_---__- ----------------------------------------- --- ------------------------------------- wner o G Address 1'nstaller -rifler Address Tvpe of Building Dwelling-------—-------------------------------------------------------- -' Other - T e of uil 'ng-----------------------------------Xs�, No. of Persons------- - - - Y. Type of Well— —- —--- - d-— - - Capacity-— - - - - - ----- Purpose of Well------ -+r-- --------------- Agreement: The-undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Priv 4&Wation — The undersigned further agrees not to place the well in operation untila > to m e h issued by the Board of Health. p Signe ; r -p- — - - --- dace----------- Application Approved By --- -------------- — -- — date Application Disapproved for the following reasons --------------------------------------------------------- ----—- -- - - -- — __----— - - - ---------- -- -- date ^ r! nn t Permit No. ----- -- - - - ——— -- Issued-__=- V_ ---------- --------------------- ;�. � date -�.�:��-�•�asas�--aesaam"ar�:arr�-^�"'�-^'�' -axa�:rsarra�aa�sFtt�M���:rFxma=�bi:�SiaraSr '��tmmta�L�a'7 BOARD OF HEALTH - TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO ERTIFY, I ividual Well Constructed ( ), Altered ( ), or Repaired ( ) �-#ING ________________________-__-___--_________-____________________—_—__________—_____-_--__—_____-_ rj Insta er at ---_ ------ �-- ------ - --- -------------------------------- has been installe in accordance with the provisions of the Town o arnstable Boar f Health—Private Well Protection Regulati/ as described in the application for Well Construction Permit No. -- - -Dated---------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. J' - --- - DATE----------------------------- ------ Inspector------------------------------------- --- BOARD ------ OF HEALTH TOWN OF BARNSTABLE Ivell Con5truct ion permit No. ------- -- - )_ 7 O ee--- —� --- ,� I)IC Permission is hereby granted--to Construct ( ter ( ), or e r ( Ind i 7Ae d at: Str t F r as short t e anplication fo Well Construction Permit No. lJ- ---- ------ ----------------------- Dated --------- -- -- ---------Z9 --- -A------- c Board of lth DATE---- Town of Barnstable P#—2,iZL3 Department of Health,Safety,and Environmental Services �Im Public Health Division Date y-Z f-f 5 Q, 367 Main Street,Hyannis MA 02601 RARera7eeLA KAM Date Scheduled Z 9-9-7 Time //%3 a Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: J3G2i✓A/GD Witnessed By: _GwrLrS /e/GfJrn/S�� . LOCATION &GENERAL INFORMATION Location Address ),Q r /N /aW8,V/AIMS 4VAI Owner's Name WM. 1eA2dn✓ /We"ltlohuh) L✓L S i 13-AAen 3 7-A17 v&4 Address 3/ G/L6t-0 A✓L' /z///✓G/ai0r�l� AIA 07,011'3 j Assessor's Map/Parcel: 10911 Engineer's Name NEW CONSTRUCTION X REPAIR Telephone# Land Use �114GA^17 Slopes(%) 0— 3 Surface Stones Distances from: Open Water Body 7 J ou ft Possible Wet Area >/o ft Drinking Water Well `/oy ft Drainage Way 7 Z S ft Property Line 7/O ft Other -- ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) d 12a�/ �iP[yy I-I��EuIAu'f /,/A�� Zak wAy Parent material(geologic) 5A/vow/eN /V0919"Ve ,5rFed-J/7-f DepthtoBedrock 7,o(J Depth to Groundwater: Standing Water in Hole: Na Weeping from Pit Face /I/O Estimated Seasonal High Groundwater GZ ZD, . nETERMINATION FOR SEASONAL`HIGH WATER TABLE Method Used: G-,✓L6wi✓b r✓ardrt� ivaT in FAv�ri Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date:_ Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION`TEST Dote Time P�2c- 8 �Z r� �/31awvarnBb � Observation ,� Hole# �JGGA✓AT3 pz_l,,j Td (�.Slvh/ Sbnin Time at 9" N�� S A.$ Depth of Perc l��G�3dh/ CAnid o Time at 6" Start Pre-soak Time© Time(9"-V) End Pre-soak Rate Min./Inch / Site Suitability Assessment: Site Passed I/ . Site Failed: Additional Testing Needed(Y/N) A/ Original: Public Health Division Observation Hole Data To Be Completed on Back—�—� Copy: Applicant 44 DEEP'OBSERVATION.HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % //JJ F�we S�Np� � Mr�SS/vt% 0AI-1 j 0 yr, N 1/�A✓ lrrzi oA3v� Godse' S/.vGr a G2.oi;✓ G6 /3S C /DYte s�3 /3 3 �tid DEEP`;OBSERVA'I'ION HOLE>LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % t7 v L/ F/L� � rbAss�v� 40A IJ/2 3�v A/ PRIA174'a WArwy r/No ® /YJlosl/✓C3 �- 33 /-?W Spy l 0%26 ,� !"2✓h!3 ry �a�sa, s�ti&-L,a G2^fV 33 T e �%/ fowr� ►o` e- 1- ?.o % G-G/2.9vL'4'.4 C'MOL,a /oB-iS6 G-3 rti�r 5'ivd —' DEEP OMERVATION HOLE>LOO Hole'# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. % DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % i Flood Insurance Rate MaW Above 500 year flood boundary No_ Yes Within 500 year boundary No X Yes Within 100 year flood boundary No -16 Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ya s If not,what is the depth of naturally occurring pervious material? Certification I certify that on �-16--9�' (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis'was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature Date -1/-3Q-f `f TOWN OF BARNSTABLE LOCH ON 144e,2 SEWAGE # i VILLAGE� ►r> -�A�J�-C ASSESSOR'S MAP & INS IALI>+ERAM PHONE NOii. ��-✓ C SEPTIC TANK CAPACITY LEACHING FACILITY: (type)P�eSrnrS (size) 4o NO.OF BEDROOMS ii ,ten BUILDER OR OWNER f V gif, PERMITDATE: 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 I 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) n /T Feet V Furnished by �� ' V {�wlCW te h O 0 + R! H4 { .a 4 s 4e,ne a-4.ot u rn d Ali 'r f ' _ __L __. .. . .._..__ .. ---.;.._. -..._ __ u.r•.wr .._ __. .. ..,,;yea_:. 20 f rn;n. -f'o o un al P ff /a ff n 0 G nc. o e c v rs H . .. , 2 Q Ga.s�' I r-orl or / e r o ' 4 .. v y f •.r �J N / ch. �i o vc. .. _ _ e'w rr�,rr. 9 nun• .ry v t Fes, . -� ._ a washed 41 P P / shed ' t 3G FnaK; 1 " .. f tc e r e a s 7"o rr e. r C 2 o v c F e. f of • . . . P P P . . 'h7irl: �tcf7 er f. P /8 p f c /e0-r7 s rrd ,n, i • low Jrne ,� b 4 � t t • .• ! :• recast lnwdi usor . e _. n o ., e o c� inv.e . # r / • G r � � S��d e t r� . r3 1100 one : bc�5e e • • e . . v e Inv. 'q e r a t 'Z , s e !t . . . e o P I 10 L e . 3 :! / Washed St nE jZ. «. }'tT r '••.K _:.. .. a V 1— ♦ice • ♦ y r. 0 b o ;. 1 x v ta r a / e/e V.- no N . und f e 2Z� 0 6P O ev bosom Best hole e! I a.. M Pam'_ F/C�� _ W/9G E YSTE - y . �o' _ a tale n t t s . d _ . � o I . / i 1 � S G /l/; ©ATA r I t . . -..: T T G� L � I , t 6 --. � NUMB'E'R OF BE©�20OMS � S H I } - - v a� z t cr N �� f GE D/ oS �L UN/T.• EST T . � T , �; � : l`,�T1� - G191<'B 19 SP R T �R E- � a c : I�J �--�3 -� k�,l'� 1.��!l T N E SSE E D BY, . � 1,. - T©T L EST/M TEO LO , . Z o x c L J / GN . . O 'GRL; BJ2. AY 8,2� PE/e O ATI,ON /2l4TE . M R/ N 1 . / P r ' 1 ' J v i RE-Q. SEPTIC TANJ� CAPAC/TY• Gf,1L HOLE /�-�OL E" � 1 � 1 c / AcTv�4L SEPT/c TANK srz� . _ GAL. © R/T ! �i ..��- G E F� H/NG AR E A ,E /�2 E M S . , . ti x � I� 7 Z x 2x. /5` • L - L.SIDE WA L GA A, iZ x .� q LE C ; ' CA PA_ ToT L A HdNG AP/9 Y o A t. is + ,, 0 / S `( w� GAL: _ t t44 _ Z l tA, L S'U `t Ya O vw 5 ot a `� Iq . LVDJ2 ` .... ANKH P : AN MATEJ�/flLS LL a :. S H A G /tlo e O x M T _,D E P• _ TITLE S l D A N E h:l E►� _ T H 7-o LV/./ o +� 7-9 6/ M , - w r G - +.� RULES tJ E D , . G � / !VS FDA' ,3 _ su .S IMF CE 4 5 ' t . 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