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HomeMy WebLinkAbout0055 HOLDER LANE - Health 55 Holder Lane Marstons Mills A= 174—001 —013 r. i t_ TOWN OF BARNSTABLE C� LOCATION 65 �6tckeo_ L h, SEWAGE # 18— Z^` VILLAGE P/076h, lhilts ASSESSOR'S MA,PP &/LOTI7y,O s Q-�913 INSTALLER'S NAME&PHONE NO. (.O " SEPTIC TANK CAPACITY XJ eL �Xl�?iv� F � J LEACHING FACILITY: (type) 2 5 (size) NO.OF BEDROOMS BUILDER OR OWNER NAY\( V h PERMIT DATE: 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 3 21 - aD ZzCe � No. / s FEE v " C®MMONWE TH OF MASSACHUSETTS Board of Health,90— Ott �k , MA. APPLICATION FOP DISPOSAL SYSHM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(?�-Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location Owner's Name Map/Parcel# _o Address Lot# Telephone# Installer's Name �+ G Designer's Name Address C7 Z!:?-1 M` //I Address Telephone# Telephone# Type of Building � ! Lot Size sq.ft. 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 Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the at#ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further not placetQhe m in operation until a Certificate of Copli ce has been issued by the Board of Health. Signed Date No. �Z tom - FEE COMMO�7��T¶ *e�. ygr LI v Board of Health, 6 MA. APPLICATION , PPLICATIO V�T FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT I Application for a Permit to Construct( ) Repair Upgrade( Abandon( ❑Complete System ❑Individual Components Location oG, jo�_ Owner's Name i Map/Parcel# ^0 Address 1 Lot# —Telephone# w Installer's Narne Fes+ Designer's Name Address .�, 2g l �` Address A Telephone# ©V No, Telephone# Type of Building 7�?PS/ 442 ,� Lot Size sq.ft. Dwelling-No.of Bedrooms a Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd l Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the 96ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further 77=1he s em in operation until a Certificate KP7ce has been issued by the Board of Health. Signed Date No. COMMONWEALTH EALTH OF MASSA'I HUSET T S Board of Health, U Health, y&Lf NJ OWk& , MA. CERTIFICATE COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The under 'gned h eby certify that the Sewage Disposal System; Constructed�(� Repaired ( ),Upgraded ( ),Abandoned ( ) by: O / //`�Y v / at A4 f 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. dated Approved Design Flow (gpd) Installer Designer: Inspector: - Date: '41 The issuance of this permit shall not be construed as a guarantee �the system will function as designed. No. Z� FEE COMMONWEALTH Of MASSAC14USETTS Board of Health, 6G'( n,S dhlo IR- MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system at G.� ' _ ���J G�1,f�J oe �.s ' as described in the application for / Disposal System Construction Permit No. / �' Z dated �—7�a! Provided: Construction shall be completed wwiithi)i three years of the date of this permit. l0 1 conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date ` / Board of Health- k ~ 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at IAI meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system 1 • There is no increase in flow 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 not 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) /a2, B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED :. DATE: 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 f- y pr7 (�✓E /5 T/ , y' I TOWN OF BA 1RNSTABLE G t�` LOCATION �s Wckeo- L►, SEWAGE # `QO— Z.` VILLAGE A�-576h�rY►i��s ASSESSOR'S MAP �&/LOT . INSTALLER'S NAME&PHONE NO.C k C.O Z4�5" SEPTIC TANK CAPACITY GYI eL Ex12�5^"T-�(�5 LEACHING FACILITY: (type) 2 L W (size) 13 0K 2�J NO.OF BEDROOMS BUILDER OR OWNER NAhcZ 1GPgAn PERMITDATE:_TA, COMPLIANCE DATE: �Z 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 3 21 cao `�1 15� Z z Ce 3 ' '! y T5 Z9 J,�. TOWN OF BARNSTABLE LOCATIONO2Q -- SEWAGE # 1 VILLAGE ASSESSOR'S MAP & LOT l7 INSTALLER'S NAME & PHONE NO. � a �( � SEPTIC TANK CAPACITY Z LEACHING FACILITY:(type) _ (size) �(l NO. OF BEDROOMS _PRIVATE WELL O PUBLIC WATE BUILDER OR OWNER / DATE PERMIT ISSUED: "'" ,.DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No tee' t f ��" -� `' L. C�� �. �� � � �- `. . � � � �e �� � �-��� ����� No.2�- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Biinpmial Workti Towitrnr#inn ramit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: ................4r f........... ca ion- d ss sY c - r Lot No. ............................. ............••...................... caner ddress W Installer Address dType of Building Expansion Attic Size Lot- V g � `��"� Sq. feet ►.� Dwelling No. of Bedroom .�,,,,�/ p ( ) Garbage Grinder ( ) pa, Other—Type of Buildiu� _It No. of persons............................ Showers ( ) — Cafeteria ( ) PL4 Other fixtures ..................................... elis�-----•------------------------------------...------------------•----------------------------•-•--------- W Design Flow.....................&0...............gallons per person per day. Total daily flow__________�30____-•----__-__-_-___gallons. WSeptic Tank—Liquid capacity&00-_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 t941k W Percolation Test Results Performed by.. --------------------------- Date...................................... ,.1 Test Pit No. 1___�`.____minutes per inch Depth o Test Pit___________________ Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x . Descriptionof Soil...._ ��ttta----------------------------------------------------------------------------------------------------------------------------- x W .......................... ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Corn h nce has been issued by the board of health. Signed ..... ----- ------------— . ............................... ----------------------------------------- Application Approved B .............:.:.- `/..._............ ------------ ---------------------------------------- Date Application Disapproved for the following reasons: ........................ . --. . ............................ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------- Date Permit No. ..... ... _�........... Issued ---------------�1<f .. Date———— t: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r -TOWN OF BARNSTABLE Appliration for Uinpuiittl urli C�u$t �r`ur#tun rani _ Application is hereby made for a Permit to Construct (U") or Repair ( ) an Individual Sewage�Disposal- System at: t 1 } r. P 55 /�' Y --------------=--------•----- --------Atzc� . / Location. Vddress r Lot No. !fc-��.f',��-��..��•, f_.�--rP..(.�:,�Gt'.±�'Irt ter--------�Y!�--------- --------�=:.�'�YL��i�7.�C!�' ddress Installer Address / 3 � Type of Building Size Lot... 3_IF....s q. feet Dwelling—No. of Bedrooms.__..-3......................................Expansion Attic ( ) Garbage Grinder ( ) pa-, Other—Type of Building _... No. of persons__________________________. Showers ( ) — Cafeteria ( ) a' Other fixtures ----------------•_-________. d �4< W Design Flow.....................&&...............gallons per person per day. Total daily flow-----------r_3.'_&.....................gallons. WSeptic Tank—Liquid capacitv/000.-gal Ions 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..---- - A�JDate. 5- 111 _1 --7 a Test Pit No. I--- .C.....minutes per inch Depth of Test Pit-------------------- Depth to ground water__._.................... LT. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - i Descriptionof Soil_ Tn�-------------------•--•------------------. ----------------.------ ------------ ---------•-•--•---•...._....._.. V .....--••-••••••-•••--...••----••••-•......----•-•--••--•••••-------•-•-------------•••-••...........••.---------•-••-----......-------••---_..._ ---•...............................................••--•------------------------•-•--•-•------------------•••-••---------------------•••--------•--•••-----------•--------••......------•---•-••-•------ U 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 TITLE 5 of the State Environmental 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 .....-...... -.... I ---------------------------- ------- ------------------------ �LTce Application Approved B -----�0 ---------------- ----- ��Z!//� Dace Application Disapproved for the following reasons: ..................... - - ... - - -............................................................... . ........... ......... . ...................... . ................ .. . . ........................... . ..... .............................................. ---------------------------------------- Date Permit No. ----- ::..._. .�..............,............. Issued .......,.....,,.;...- - -...✓....��.�...... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , ` Tertifi ate of LI����TT-II>r plianre f THIS_IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by jo �) G-� -- - - i all - -- - ... - - - - .................................................... at ..-----"�.........tO---------HD4-4—F-62----------1 -/L/- ------ny� - �--�.t--L" rj - ...-- - - has been installed in accordance with the provisions of TITLE i of The State Environmental Code as described in ppDisposali / 'the application for Works Construction Permit No. ._.-._.... .._'.. . dated _...: .... /' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUEA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Inspector .DATE..... - - _ ------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f TOWN OF BARNSTABLE, Noes FEE.... �. %papal Works Tonstrurtion ranttt /� 1-5 C" Permissionis hereby granted------`-` ......�-------------------•-- -------------------------------------------------------------------•----------....------•... to Construct (\J) or Repair ( ) an Individual Sewage Disposal System at No......J!nZ).! 1 U-----i L h 0/" L l u �= in (LL-S Street / —7 - as shown on the application for Disposal Works Construction Permit No:-�,�.-�1 ated..-. f --.- ...--.._.. ------------------------------------ --.y--- s......._....�.. - ---.'.4...�`,�.�� DATE - ... 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