HomeMy WebLinkAbout4260 MAIN ST./RTE 6A(BARN.) - Health (2) .0
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Town of Barnstable
Regulatory Ser�ices
°s Thomas F. Geiler, Director
l` ASSBL& Public Health Division
Thomas McKean,Director
•• ; Y.� 200 Main Street, Hyannis,MA 02601
i
Office: 50 -W 4644 Fax: 508-790-6304
Date: Sewage Permit# 'T5_assessor's Nlap/Parcel
Installer&Designer Certification Form
Designer: ` �, � Installers: „�� �F �JL
Address: C54ga' l'G 'l Address!;
i
On �� /�f ��r��`�✓ was issued a permit to install a
(date) (installer) i
i
septic system at _�Zbo W 1 1 11 based on a design drawn by
(address)
dated
(designer) T�
/ I certify, that the septic system referenced above was j 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 v:ertieal relocation of any component
of the septic system) but in accordance with State & Local F '-Lions. Plan revision or
certified as-built by designer to follow. Stripout (if r? Pcted and the soils
were found satisfactory, P�\ 0`Mq \
ss
DAVID
B.
r_,•.;.
(Instatler's •ig re) MASO�J
o No.1066
J 9 O coft'
• Js-
esib er s Signature) �`��lti� ; ,J .�; •����
PLEASE RETURN TO BARNSTABLE PUBL., �f E
OF COMPLIANCE WILL NOT BE ISSUED UN i iL, !isu i ri i tii, r UR NI AND AS-
BUILT CARD ARE RECEIVED BY THE B.ARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
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Town of Barnstable P# D
Department of Regulatory Services
i Public Health Division
S1
�. 0II Date
200 Main Street,Hyannis MA 02601 .p
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Date Scheduled
Time Fee Pd.
3 �
So Suitability�Assess' for SeW"' Disposal
Performed By .,
• Witneised By:
_ LOCATION& GENERAL INFORMATION
Location Address 0 :�o �)�j�7— Owner's Name (5=2;,-ge G�J
Assessor's Map/Parcel: `.z "l �sO
�.! Engineer's Na
NEWCONS7RUCTION REPAIR _ Telephone#
Land Use- _ rs ' >�
Slopes(%)'`� j + : '' "��Surface Stones'"'� t.
a
Distances from: Open Water Body ft Possible Wet.Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other t
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
a--a — Q
-? 5-1
^ r"^
Parent material(geologic) Al Depth to Bedrock
Depth to Groundwater. StandingWater in Hole: a
Wee PI Weeping from t Face
Estimated Seasonal High Oroundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: In. Depth to soil mottles:
Depth to weeping from side of obs.hole in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level -„ Acil.factor Adj.Groundwater Level
PERCOLATION TEST bete Thne
Observation +
Hole# Time at 9"
Depth of Pero � Time At 6"
Start Pre-soak Time® t" t t Time(9"-6")
2 i
End Pre-soak '
Rate Min/Inch , r w,
• i
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back---------
***If percolation testis to be conducted within 100' of wetland,you must first notify the.
Barnstable Conseirvation Division at least one(1) week prior to beginning.
Q:ISEPTICVERCFORMMOC
DEEROBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
n ' tenc rave
^ •�(� In 3 1 _
�i 44D 1 SAX TPWL-PR-
on
for
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
ons' e
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%O ve
t
DEEP OBSERVATION HOLE LOG Hole,#
Depth from Soil Horizon, 4 Soil Texture Soil Color Soil Other
-- Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.
t'
Flood Insurance Rate Map: �
Above 500 year flood boundary No_ Yes
'� r
Within 500 year boundary No '' Yes
Within 100 year flood boundary No, Yes
Depth of Naturally Occurring Pervious Material i ..o
Does at least four feet of naturally occurring pervi u 'terial.exist in all'areas observed throughout the
area proposed for the soil absorption system? ' -' ;,
If not,what is the depth naturally occurring pervi us material?'$ ..
Certification 104
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environ ental Protection and that the above analysis was perform by me consistent with
the required training,expe a d,a ience described in 310 CMR 15.017
Signature Date .�O ' �b�✓
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TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE ASSESSOR'S MAP.&PARCEL
INSTALLER'S NAME&PHONE NO. �
SEPTIC TANK CAPACITY If-d',ee- �rvO 094l:
LEACHING FACILITY:(type) (size) c:�
NO.OF BEDROOMS
OWNER 6r'
PERMIT DATE: �`� COMPLIANCE DATE: '>`r�10'03
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 3F-1:rFeet
Private Water Supply Well and Leaching Facility(If any wells exist ori'
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
FURNISHEDBY
&AILI✓
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No. 1 Fee
1' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
I2pplitation for Misposal *pstrm Construction j3Prinit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) kComplete System ❑Individual Components
Location Address or Lot No. 4,g ero -'7 wner's Name,Address,and Tel.No.
Assessor's Map/Parcel S`� o f er
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of'Building: rom
Dwelling No.of Bedrooms 7�U`� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building v��f- No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �;�0 gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank. �` S'o el �'�Z, Type of S.A.S. cP ekg, -
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Certificate of
Compliance has been issu is Board of ealth.
ed, Date_-<—,P2 67ILI
Application Approved by Dateokzl
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
------------------ -------------------------------------------------------------------------- ----------------------------------------
w tooe -. Fee _
' r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION =TOWN OF,BARNSTABL-E,,MASSACHUSETTS Yes
I o
01pplicati0n for Misposal 6pstem,,Construction 3permit
Application for a Permit to Construct( ) Repair( .), Upg ade"(' ) Abandon( j` mplete System El Individual Components
Location Address or Lot No. X7 &T wner's Name,Address,and Tel.No.
G-�
Assessor's Map/Parcel r/ O/6 i 3aZ P'r/
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
I
Type of Building: r„�( / t
Dwelling No.of Bedrooms 7 (JUG— ((//�J l!�lLoott Size sq.ft. Gatbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) `Pj0'0 gpd Design flow provided gpd
Plan Date ` ' Number-,of sheets / Revision bite
Title tit'
Size of Septic Tank 40 e'bii S"o o Gad 1, Type of S.A.S. -P
\ Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Z.
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.Certificate of
Compliance has been issued-by-this Board of ealth.
igoed, Date
Application Approved by l /I d Date
4
t Application isapproved by Date
L...
for the folloNIng reasons
7
Permit No. Date Issued
_ ---
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS -
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
- — Abandoned( )by t,� /Jl L G��D��� J'e�4�iC JE&2"!O/Z� J
at �O /!�►�//Y J'T GPJ �iq has been constr ted in accorde
with the rovisions of Title 5 and the for Dis osal S stem Construction Permit No d
P P Y
Installer VJ /J9 G���OE`�/}t` Designer g"d'ib j& ,W,4J'0rr /L>,LP
I. #bedrooms Approved designn fl w p / r, / gpd
The issuance of this permi shal t b no c nstru as a guarantee that the system will . t
ry
as esi ed,
Date Inspector '� T
--------------------------------------- _
by .�
No. 1 Fee,5_
/
HE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at 5 2 6® i4/r' .JET 6rl C m /f 4vFo/d
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must coMlete ithin three years of the date of this permit.
Date Approved b PP Y
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AssEssoils MAP : Nu�rf;�:
PARCEL :
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y r LOOU ZONE: /pT f,ZJ -- -- SOIL EVALUM 011: I � C 1) 'I he installation shall comply will)'Title V tool 'l own of' �jq(jyl�l3uai(I of
---p /- G � WI CIJESS : ! Ilealth Regulations.
REFERENCE! oL,C f�,/ .r �— i 2) The installer shall verily file location of ulililies sewer invcrls and seplie
_ DATE: .5V"E 01�
4�+-111. 3,e Yry a � f EIICOLA f 1014 11A 1 E: �G„ ll,�/ E�v
C011ll)uI1eI1lS t)flUr lU installationilll(I Setlltlf; base elevations.' 3) All gravity septic piping to be 4 inch Sch,Itl I'VC rrt 1/8"per lbol. The first
EEc5ule ,'O / f �96 f ►�` - two Icet out of ll)e d-box to file leaching shall be level.
�, 4) 'l his plan is not to be utilized for property line dclerurilialiun nor any other
A �� U/1 ►�l10 1.vk1M/1 purpose other th(ur the proposed system ins(allation.
N lCy�3 L. �' I� 3 5) All septic components must meet Title V specifications.
Q b0hM 51q,lD klp G) Parking shall not be couslructe(1 over 1llo septic cuu)punents.
"""`• P'y �``ro �� i2V� �b ,r d rt,{p` �� 7) The properly is bounded by property corners and property lines.
LOCA 1 1014 NIAr "X s) 'l*lie properly owner shall review design cuusideratious to approve of total
design flow and number of bedrooms to be considered lbr design. Receipt
' hlgc� of payment for the plan and installation based on the plan shall be deemed
I d "ICJ -- NED,5*Jp
Cyr I approval of the design flow by the owner.
0 / �joU�bf`� WI `✓ 9) The existing leaching or cesspools shall be pumped 1u)d filled with u)alerial
%l I� �by fL�l per Title V abandonment procedures. Those within the proposed SAS shall
f �L ►► i be reproved along with coutaruinaled soil and replaced with cleau sand per
Title V specs.
10)System components to be 10 leet liunr wafer line. Sewer lilies crossing the
water line shall be sleeved with 4 ineh SCI 1110 PVC with ends grouted it'
/� { 'LC.I��'���fa/GJ�•l Zri ' 1 �T�' 1`' applicable. The proposed SAS is being installed below (lie water service ;
�I _ _
� � S �1-� �1• I C S Y S"I L- Iv1 D C S I Gil lice. The line is to be sleeved as alorenrentiuned and maintained in place.
CIo4O-UT J 11) If a garbage grinder exists it is to be reuroved raid is;the respuusibilily ol'(he
owner to ensure such.
FLOW ESTIMATE I 12)'Flie installer is to lake caution ill excavation around tiie gas line il'such
exists.
— — — — BEDROOMS AT 110 (,-AL/DAY/SEUIIUUI,A -qq� GAL/UAY 3)Tlre installer shall.veril'y the location, quan ily and elevation optic sewer
lines exiling the dwelling prior to the ins(allation.
— —-- ,
--— — •— ——� - SEPTIC TAIJI( 14)'I-his plan is representative only that a syslen) eau lit on a property rueeling
O
Title V requirements.
GAL/DAY x 2 DAYS - GAL
USE 1�00 GALLON SEPTIC TAIM
s�v� . EkC�k�►-� c15' �2Dvc�.�tp �� ����''L'��-_--(,�Q.I�tL� 1•dCJr �l, l�w�
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- - DATE � I IL"AL111 AGEII f � '
-- -- - ; 1508 ) 833- 2177