HomeMy WebLinkAbout0116 SHALLOW POND DRIVE - Health 116 Shallow Pond Drive
Barnstable, P
A = 254 021
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Town.of l
f Barn L/S table
of
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Department of Regulatory Services a�
BAIMSTABrA : Public Health Division Date oC
t6J9 ,6� 200 Main Street,Hyannis MA 02601
f
Date Scheduled ,� 1 r _
Tim Fee Pd.
Soil Suitability Assessment fog- Se e IVOS,
Performed By: Witnessed By:
LOCATION& GENERAL INFORMATION
Location Address &A Owner's Name
_BdAnS�z"_ &Address
Assessor's Map/Parcel Zt-(4 —D 2 I ,
Engineer's Name � ^ =
NEW CONSTRUUMON REPAIR Telephone#
Land Use I&J 1 Q"j7 0 Jrd Slopes(4'0) �'-? Surface Stones
Distances from: Open Water Body 7 ZOC1 ft Possible Wet Area Z 0a ft Drinking Water Well eft
Drainage Way a v `ft Property Line ft Other ft
SIM-TCII:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
a�
_ N
0
Parent material(geologic) Depth to Bedrock -
-n
03
Depth to Groundwater. Standing Water in Hole: cam/ Weeping from Pit Face
Estimated Seasonal High Groundwater 7 3 L.,
8 _0
DETE ATION FOR SEASONAL HIGH WATTdR TABLE
y
Method Used: _ S a f ` VC/ > �c
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 n
PERCOLATION TEST bate Thne
Observation
Hole# Time at 9" �. —_—
Depth of Perc Time at 6"
Start Pre-soak Time @ Time(9"-6") -
End Pre-soak (lP 7 y J-
Rate MiniTnch
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 test is to be conducted within 100' of wetland,you Lst first notify the
Barnstable Conservation Division at least one (1)week prior to beginning.
Q:XSEPTICIPERCFORM.DOC j
r
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil. Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
on istenc % ravel
0—Z-7 r `�
Z -3-z? A —15 )0�4s14 tiv
-1? c 1 t Q�►�S�w►c� i o y ,v0 TO crestj�a�ofo~
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
C ns' a % ve
�bzf �P�i
CrW 6,.-&
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consi ten I
hood!nst ranee Rate Man:
Above 500 year flood boundary No— Yes
Within 500 yearboundary No_ Yeses r
within 100 year ficM boundary No._,,,_ Yes
Depth of Naturally Occurring=Pervious Material
Does at least four feot :,f naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? �
If not,what is the deptll of naturally occurring pervious material?
Certification
I certify that on _ � --(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 trainin ,expertise and experience described in 310 CMR 15.017.
Signature � Date `
Q:1$BPTlL\PBRCFORM.DOC
�C � .�q y 3 F �,,.c
S< CONLMO V r.3:.:SJa-T11 Ut, t�
OF EN-VITRONINN052N -AL PROTP-CT'ON
DRPARnmEN
TITI ��
O�CLAL-IN FORM—NOT FOR VOLUNTAR : ��
SUBSURFACE SEWAGE DISPOSE..SYSM ORIM
P-ART A APR 2 T Z003
4 � O TOWN OF BARNSTABLE
HEALTH CREPT.
Property Address- �`ivt-
et
ownees:`&ante:
Qwn-ees Address,
dd ess: k`N- Sono MAP
�•��cle . (`f�Ps Da 63�
:F�ate of PARCEL IZZ�2
ecto-iF�e p LOT
�iante of fnsn �`) •�- `- - -- - -
COMP=Y dame: —
A142P-hng Address '�$1
Ci g Yyy,-L!C AAIO SAATE
1 EN- R ' 1 •i o-"L'eG
cemfyi�aieiy s. y iSS 'sy 3 az s address and LLbt�Lr
based
—ia f,Le ins4 itli-1 :z' " " uiy
below i tee,acccM Le and cornpiete 8S of i; r t3_''
?a i and eXB eµCe n'd1e=r°p~r T'imwm maintenmce a u�site sawaae disDosat syste,zs_I z a =P
apuro y ed system inspector pU='sMaU±'tD Sec�ia!534E of Title 5(3��'����_t�£3f3). 'fie�e�'•
JC Passes
Ccmdi_iot Passes
-News Further 'vajuzdon by the Local Appr0' M9 Aut .o--Y
Fails
3 eeao s$ a�3'E:
r� D2te:
1� �3
t�- a__reps:to the Approv Author': (Boa-tl o"_�eai�or
the system irk cto:shal submit d CWy ai � �a S:�aTed SyS�'or has a deSip f?ov<a="1C,�3
DEP)within 30 days of COMO t�i-ahis ice.=-it ige system _
r and the sys*ems owner shall sLbmit the repo to:be at�opr�=e1onai oMce of+
or a3eater,the inspect i fa if apis£:cablei�'he ap!=VIg
�F'�'.the or:asa?s?trs�.t_d lje sera to the system owrtes at=d copies s ::o fire of;.r,
Ni-ates and Comrr=ems
y -s2�of we at 6�t
x *Tf�iS rtDoTE O iy es�� ct3tiriit'�oris at:fie time Of i�pe t3fl and a e.
hsn d zsof atiress Ito Xe Sr3teT. •Lir= nte` tees the same c�z different
�orri�os arse.
r
OFFICLALINSPECTION FO� M Rg -N FOR� r � � SSINMN-�'S
POSAL
SUBSURFACE SEWAGPART A
CER17IFT-CATIO-W(cones;
Prop Addre 1�6-%Ab A -Ro4 r'k ve
Owner.
Daft of Win: 31. 1l( o _
inspect Seminar : Cbeck AACD or E!ALWAYS sops aff . s
A- 6wstem Passes:
X _ I have=ford any ifs which M&CMsUbtat aril of the failure tmria described in 31ri Clvm
i 5303 or in's 10 AR 15304 e Any cz-.wig Lot ev hated are indicated below_
System CondifiewIly Passes:
C-r a or more systezn components as described in the-Condmonai l' "section need to oe tepbsed or
repaired.The system+;i on completion o2 the replace crr Vic+:as roved by-&e Board of?-feat;will,l
Answer yes,no or rzot dezeranined fY,N-N 10)in dhe for _ followiafg statements.if Imt deternfince e
explain
'Me septic ta--tC is metal and over 20 years o are the serer tank(�hetber tge a?or not)is sex.
unsounc,exhibim substantial infUtradon or exf i-I or tank bffize is imminem S will ys pass msaetiftne
exerting tank is replaccd with a comply as approved€y the Board of Health.-
,*A mew septic tank will pass msperzon if sauct nzily sound,not leaking and;f a Cerra.fice�rff C M&=
ir
.dicatmg that the tank is less dna 20 old is available-
ND ex la n:
Observation of sewage b ka 9 or lam om cc le4el in the distrikwraaa box due to.bmk=or
olasaumed pipe(s)or due to a eii;settled or t -X=?b en box-Systmnn wffl pass mxpectim i£f
approval of'Board of Fleail
broom isms;am itplamd
obstimction is reared
distribtudim box is eled of reps
?ate e { '
1 lae s required pumping more d=L4 mnm a.year due To broker.ar obstracmdpw.ef s;.:`fie system wits
pass iY7 if(with approval of the Board ofHealth):
br&e t ppeW arerVhaced
obst'iuction iS removed'
NO explain_
Page 3 of I I
OMCLA, 5PEMo N FORM-NOT FOR VOLUIN '4RY ASS—ESS *-N-TS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM SPE 0N- FOR-
PART
C" C A ON(coati ned)
Property Address-
Owner-
Date of L3dSomfion. 5 n _Q,,,
C Further Evml 8tion is ui ed by the Board of Heak -
Condr,tions ctist which requke j .-r evaluation by the Board of wealth in order to deter mme-if--he sys
is ti a to protect pult3lic health,safesy or the etivUw—Me L
I. System coal pass umk:ss Beard of Health determines in accordance with CNM 15-M3(1)am)that the
system is not fungi,in a tnaauner why wM protect public h ,sat"ety and the euvironm st:
Cesspool-privy is•vithin 50 feet of a surge wamr
Cesspool or privy is 50 f�et of a bo wedand or a salt ash
System will fail uniess the Board a= 'ealth(and Public dater Supplier,if any)determines that the
system is functivving.,in a manner t protects the public health.safety and environment:
_ Tne system has a septic aad soil absorption sysum( 6)and the SAS is vrahin 100 zet of a
s=mace Ovate:supply or, nary to a sw,face water s g"lv_
the system has ptic tank and SAS and the SAS is Adthim a Zone i of a public:per supp',,-
Tire system a septic tmk and SAS and the SAS is within 50 feet of a private vrater Supply We&
_ T---sy_ has a septic tax&and SAS and the SAS is less dzar. 100 feet but 50 feet or mo e fry a
private .supply we{f$*.-Method used to die-s' n;=
=his ystexn passes iftLe;e_: '-anazysis,performed at a CEP cep:wed Iabomwry,far eoLQ
l and va ars`ir r Mwk compounds h ates dw the-well is free�po on from that fees and
the ce of ammonia oivoQen and nit-ate nitrogen is equal to or less than 5 pp--1,provided that no other
fa criteria am triggezed.A copy of the analysis must.be atmcs to this form.
Other:
V
O"MCL&L P6PECHON
9i j$�3��sR'7� �e-�gw�N�a��a I Fc��g �T'�S]�� : A
��✓ �$ �3. s �"4`iS�e 1r'SiY�. 'OJY $Yro 3 a. �+�. R
PART
-D system FaRareC f3am
you "or.. -t.'�a eMefoRowing iFor29R' "r- = .
Yes No
SAS is
iX'to e sur&=c groaW CF-S%Lrft=Tw"c.�.c��"'5—'ke W M iVs,rf sal CC
cwggm SAS or cessvocd
ovesloa&C or 6�SAS or
CeSSOODII
. .� -� 4� �d ye �e�d�Or em s :
� l
.-�3�€3f�SA&��p"z ivy � Ns'�e V *_.
a4 a DEP�----fified�,- CoNform bacteria aad'ram
as
To =.�-�a e sfs` the s m _a te 2, ew to L c'
es �-
Ufa- sue';v rd1 .�
If s��' '' S`� ' r '�-�"
Garc:�i�s S 'For�a i ae r Sf'c;} _u • -�s'he syster"1M3C :13".�%L=Vli�..._�!
OFFICLAL RiSPECHO €FORM—NOT FOR VOLUNTARY ASSFSS ?z�
SUBSURFACE SEWAGE DISPOSAL SVSTE-TA-U4SPE € N FORM
k .T B
C C!dI-�
Properv, Address; ?0 DV..
rA .
Bate of Insmedon_ ZS l'11 103
Check if 2hv followig been.done_ Y--ra must!%&cam 7!y s or z taC as to each of the foilowi :
r
Yes -No
!C Pumping inr�ormauon was provided by the owner,oc.•-s_YPML or Boas Qf Heap
T JL Were auy of the system components pumped am m the previo'.s t wo w-eels?
Has the system received norma!flaws in the previous two week period?
Have large voices of water been innxx�d w€he system,recently or as part of this i on. `
V Were as Milt pis of he system ob&ined and ems? ',If fey were am available mote as NiA)
Was the facility or dwelling irspected for sites of se r��ge back--*p'
�( A "Was the site in-sv=cd for signs Of break out
OC Were al"syss�5'Ts compo-nents,-excluding the SAS;locates on site
Were the septic mnk manholes tmcav red,opened,and the interior of tie tank-in eted:ot the cotsrti'uor
of Lire sa les or tees,Ttzateral cf cons�cor., ersiors,ceps of liquid,c�etTtL of sludge aTid depth of s ?
}Brass tale ik-t-H y owner(ar_d ocatwants ii diner-e it&ozr owner)vrovided with in o mwion on t_he proper
ma--;te-nance of subsurfr^--ce sewage --Sposat systems
4
The size and motion of the S€R Absorption System,(SAS)on the site been daermined based on:
Yes no
,1( _ Exisang iF2fCfr arion-For exarnpm,a.plan at the Board of lieaiu_
Dete`rmmi ed in the field(is any of the H-hut critma rel�t 'to Part C is at issue 8t)ptoXim- atlo::oirdism,,M
i$t:iirlCCCplarJleJ B 10 Ck E 1_302(3)(bFi'
r ..
FART C
lAw 6ba
a 'Or ` W
S fives o+=�),: *.)P
WOW Mmer -if aa �e 2 vem USW O L b- Z
Sw cr n*�
���=
CO CMULMOU" .�
iv
Des!V flow fbesed on 3 10 CWM 15<�'� 04
cw�ump F---Zm 6--or DOD:
lm�
waste=---h - s�5 .ems W 3a�
0 TH K RI(d e s,c ,)
4. -..
Reewds
S ' ���� sic
was sys as part.off or WX PD
Vanes—11-aw
s s
Reason f�ar pw-npiw
rFF SYST"E.Mf
y_Sep=tom, box,sue`€ s
S
Shama syv�(yes or:moo)i9 yes. _
wi-hL Mk Attach a copy
��M� =
�e age c _. knows)
NOT FOR VOLUNTARY
ASSESS NIM
O FIC.-IAL pqSpFCTj0NI FORM
S3'BS ,RFACESE;YAGF-DISPOSAL SYSTEM S LCTIONE
FORIM
PJARf C
SYSTEM LINTFO'Z A-11ON(canting)
Propert'g'Address:
`l c
Owner t�Jbb 0, L —
ate
of Inspection:
BUILD LNG S WER GOCae On sxte p# �
Depth below :_�D
-teals a` uw c =1�' 'C_ ( )=
D, ce fr+otrt private wamr Txpply well or suction linesmn : . .
Coame (on edition of,a .venom,evidence ei hake,etc.}:
SFynC TA='�t-is,: X (lode on s'M Pi an)
Dept mow Grade: &O�� 3 ie�P
of cons :a : K ca=crete sera=_3t ss o-Ye Y
�oder(explain) y r &--ach a C07-Y o?
�="Lank is L:teml list a&e: is age coniumea a Certificate rate of"omplia-hce fives or no}:_(-
CwTificate)
Dimensions: OUO
Sludge depth- 3" d
Dice from Lop or judge to bottom at oL:£lez zee or bate:
Sin thickness:a. , to
Distance�£n top of scm to top of ou-�et e~or ba_ e: _ u
Distancebonom of scumto bottom of o€;tlet-`�
'Rosa *ere dimensions d inc-' Iryi easo d-e•C ty condition,s�sn�l int�irr lsysa tl levelsCmum.ems(on vurn;;ing reco;Mend ons,inlet and outlet tee or
as retjted to oi3£leL iS1Yer"L-evidence of 1p6.�'^�e,
fA�Ic u•�as s o u�� o.
GRF-ASI; RAP- (lpCaLe or_site PI833;
D be:aw e ___ nc'veylene oyster
Material of corssMctiaz:
(explain.):
D�sersions:
ScU' &ickness:
Distance ftrn wp of scum to top of et tee or hasxle:
Dis'mce ftcm bona of scam to' om off outlet tee or bale:
Late of last pxnpin?: ' -id leveis
Ca�ttner�is(on_p��p�rec £IEL�ationS,?I£�t and outlet tee or baffle conttttfo't,scrtacturat.r£e�.t"�,stet_
as rZ�10 odld Le or 1 e,e c}:
P
age S of 11
OFFICIAL RqSFECTION, FORM=NOT-FOR VOLUNTARY ASSE�SNIM
SUBSURFACE SEWAGE DISpOSAL SyST sTE ON FORM
PA-RT C
SYSI 'FOR A OT
'� ( )
Q
fir: {1✓bbac
D2te of Inspection: Z 1?1 0." .
TIGHT or HOLDING T If,: ( nwa be "at fme of t 'M sim Pam,
Depth below
Material of consau€tiow- concrete e b" _Xolyethylene owe:yes
Capacit)r ons
Design R- o�t3zv
Alarm present,(yes or nto)
Alarm level: A M wMiang ordrr OMS o=toy
Datee of last;wv
Costaems
of alum and Boat switcbes,ex-)-
MISTY l3'1�s�3 C (if present muv-be opened) 1=11 I Site Diatr) `
of fiqu L level above outlet invert e V
C�(�if box is level and disv-lafion M;,IY�S equal.any evic�ace of solids a�yo�er_any ev ce of
!ease irto or out of box,e-c-): h Q S Ash o"Y C0.t'r`�[ 0 tlX,
-Tl� 6 oat comas (eye ( a�.� �•c.��' `
Pia CHA'9B�: (:tx�o�s� �
Ptmps in wo-�g order(yes cr- -
Alaruis in working order{des. �): etc*
{�€e co� l� ber, Of -
,eyoi it
OFFICIAL RqSpE-M0-N FORM-NOT FOR
YOB � '-AEN-S
S�-BSTj �£E S'�kGE DISPOSAL S�S � ��
KM
PART C.
SYSTEMI L.W< RMATIO(
Property AddreSS tIL S bW a v
Owner:
Date of Ins Z
SOIL ABSOR-P'L It3N SY MM(SAS):= (locate on sizte pl'an,excavation not wired)
if SAS not locate erptair.why-
Type
} .pits,numb-f
!eaching chambeersr .
lj. c itsa gailere,U.M:a3er:
ieaciiitrenclaes,Niue_s,iW'
lea6in&iiesds,numabear,dimen is s:
over3ow cesspool,number:
aovavesaf€ers±x�we syst. e n£tchnolo3v
Carr s(me candiEim of SOILS of h)*Wuh,-failure,level of i �=>�aan�.soil_��-'Borg of vege��((�� Q
CESSPOOLS: (ces a wim be Dum d.as pan of kq?eCti0`')C10 `e on site pian)
Nunulrur and configumadon:
Heath of Soiidsuye:
eDepw of scum hYer-
Dimermons of cessPOOIC
Maza.:S of Ca
hj&c�on of agound` inflow(yes or no):
r- i c.?L'�raioi?o ve`-e' or_.e:C
comr—jeers(noate mon of s0iL SiPs t;a yCltci:itc f rtur level G3i C' ? ,
0ocam on site 2P)
Mz=etials of Co. n:
Dirnei :=3s:
Dzy-ji of solids:
Catrtmer (- caadition of Snit,S"MS of hv&auli£fail e,ievei of pood.4r cond Lion Of v =0n,mac.}:
r
Fm
_ � --� FORM {:
�3 & DISPOSAL-
PART i L ?
SUB
. o C _
owean .K�
of
a1Fi.
VJ'
:.
R e0,
3e a '
0
Page 11 of I 1
SF �-N FORM.—NOT FOR VOLU ARY ESS N' TS
SUBS U A SEWAGE DISPOSAL SySTE I SI'ECflON FORM
PART C
Propem Aditess: t11
€ wner- R
D�aie o3 ius .ion:Z
SITE Eywm
slope yes
Surface water 00
Check mar 4'$
flow wells V,
Eseb:sated dep6 to--ot.rzd water an{
Please radiate(check)a€i Meqbods used to determine the hqA ground weer elevation:
Oared Lmm syszem design?=ans an record-If checked,�of plan reviewed
Gbse—ared s=te(abiwina propen.Wobserration hole with-in 150 feel os SALS)
CRecked with;oval Board of Heahj-e lam:
Ct ecked with local excavators,installers-,amch doamentaD )
Accessed USGS dambase-e)Ttain:
You must describe how you established the high ground water elevation
�6',S �0.�� S_ ��oyJ o�..�, ¢.`¢.V(s�'loV� O � oY•t/�
*114 TOWN OF BARNSTABLE
LOCATION �/� f� �ia��c��/ �'r�rat?11e 11►C , SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & -PRONE NO.
SEPTIC TANK CAPACITY ). ?
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS� PRIVATE.WELL OR UBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
i
�Y
1>
" fit.
No.... ��.-.�.�6 �! FEs......1.6-40..........
THE COMMONWEALTH OF MASSACHUSETTS p
F 75 BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphra#iun for UinVinial lVnr1w Toutitrnr#inn ramit
Application is here Wade for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal
System at: 17
L.. 4lr..... S4, COlV�D`Jt/O A� ----------------------------------------•--------•-------••••--••.....---
T. .... • --- ......E ..
Location-Ad rr•ss r Lot N
/ GL .s - /L/�/�/(�..-- `c5 ��....................�4�!/ni G / //f�//i/J5
.....................
a .. owner Address
. :
-------------------------------- -------_-- --Installer Address
UType of Building Size Lot-__� _Y _._Sq. feet
Dwelling—No. of Bedrooms-------3................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building --_-_--__-___-------------- No. of persons............................ Showers ( ) — Cafeteria ( )
aOther fin tures ------------------------------ -
W Design Flow....,�� �. . .. . .............gallons per person per day. Total daily flow--------5311_------_---__--_-_____gallons.
ri
W Septic Tank—Liquid capacity/d/0..gallons Length-_- ___ ____ Width...:A0_ Diameter---------------- Depth_.r$'.I
�.
x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No---eIVI ...... Diameter----/0........_. Depth below inlet........ ........
Total leaching area---Z/"s -sq. ft.
Z Other Distribution box (-,() Dosing tank ( )
Percolation Test Results Performed by....1-,-fYY.A�VO...6V_,0/14 5A6C............. Date...... .........
a Test Pit No. 1---4._2---minutes per inch Depth of Test Pit--�Z----------- Depth to ground water./ 0. ��
Test Pit No. 2................minutes per inch Depth of Test Pit--------_----------- Depth to ground water_.....................
a+ ............................... ..... ------------------•-----•-•----------------------------------------------------------------------------
0 Description of Soil___________________ _-_/ �� T�rASI.tG O ..___.-_..__
x ------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------•-------
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 .. ---- - ........ ------------------------------------ -------------------------------
Dace --
Application Approved BY - /./.-.. .. -.` .
----------------
y
Dace
Application Disapproved for the following reasons: ..................................... .......................... . ....... . ............ . ..... .......
--------------------------------------------------------------------------------.............------............._.....--------------------------------------------------------------------------------------- ................................
Permit No. ------T-Li......... .zl&----------------------- Issued ---:........ j^ ^� .
/l -
Dace
THE COMMONWEALTH OF MASSACHUSETTS
I
75 ,��� BOARD OF HEALTH r.r _ TOWN OF BARNSTABLE
r b, Alip iratiutt for Diuvuuttl Workii Towitrnrtiun rrrmit
1 Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal
System at: // 1 ` ) ;°
L 07 A10. 16 �tl� �t,d
-•...................••-----........---•---••----•-•----...---•------------•---.........--•---.... ------•------------------------•-----•---....---------•----.........------------•-•--•---••-------
Location-Address
NA61<v6d9.s _&liL.)/i✓� C'a � C�i�9</�✓i� a S l�r/y�°tlf/fitiiU/5......... ......
.....................-...•--•-•---.........•••-•-.....------ --- ---- . •-----•----••-----•---••-•-•-•-
Owner ,/ Address
Installer Address
U Type of Building Size Lot...''�7.��� S feet
Dwelling— . o. of Bedrooms._-_-__ p ( ) j'�1 g q( )________________________________Ea Expansion Attic Garbage Grinder
Pk Other—Type of Building _---_--------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- ---
W Design Flow----11,0 41,91)1,2121..............gallons per person per day. Total daily flow........ --54.............._..........gallons.
WSeptic Tank—Liquid capacity/0D10..gallons Length-__,"3-_A/o----- Width.- ... Diameter---------------- Depth-. _....
x
Disposal Trench—No- -------------------- Width.._.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...Q C...... Diameter-_--�Q_:..-----_ Depth below inlet........a_....... Total leaching area...Z_I.A�sq. ft.
Z Other Distribution box (-)() Dosing tank ( )
a Percolation Test Results Performed by---- ............ Date------ ............
Test Pit No. -_-minutes per inch Depth of Test Pit---1Z........... Depth to ground water_/107�!
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
P4 -------- ---------------------
O
Description of Soil..........--------Q--,./Z'�--T1��4_;SU3SQi�L---------------- -- --------------------------------------------------------------•--•----------
� •-•...........-••---...-- "•� %°!�fl _. ' ' ... 11Ty.S_Ta'!/F.
w
------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•--
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 ------ ...1...... -------- ------------------------
................ ...__.....:..------
Date
ApplicationApproved By --------- ----------------------------------------------------------------------- ----- /
Application Disapproved for the following reasons: ............ .............. . ---- . ...................... ---- ._............
------------------------------------------------------------------------------------------- --------------- ---------------------------------------------------------------------------------------- ........................................
Dace
Permit No. ------ �'4--. -----6-------------------------- Issued ----------ff� ��'r "9.l.... -
------------------------------------------- ------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(gertifirate of Tomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....... . ......... 1 1' �1?. c -----.'...... _ ;---------------..... - __...............--------
` (} Installer
7_
at ..---------1, 6. .:v. ��1'... �p ^.......� n 1—- ----- --- -------------------------------------
has been installed in accordance with the provisions of TITLE 5Iof The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .._-. .--.�-.. ..-6---------- dated .........�(.�_�. }_...r...C/�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU A AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE -----/ ... ... ""- ------------ � .... ./`.......... Inspecsor" ;:-.: r' .
------------------------------------------------------ -------------------
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE J
Riipuual Workii Tunutrurtiun "omit
Permission is hereby granted.........H`-Q-e''-`•i Tf�- ls�G-�z
to Construct ( 4 or Repair ( ) an Individual-5ew age Disposal System
atNo..........Z- 6....:. •--- - .......P- -----------------------�o P_A r)
Street
as shown on the application for Disposal Works Construction Permit Dated...........................................
-------------•--•---..:-•---------•--•--------------------------------------------------------------_....
Board of Health
DATE........................................•------•--------....--•••-------•.......
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE I
!� % t��
LOCATION /�/�',Z�����/�r,�„/ t��.i;� SEWAGE # Py-4 n(VILLAGE' � � �, ASSESSOR'S MAP & LOT
INSTALLER'S INSTALLER'S NAME 6c PHONE NO. k�
SEPTIC TANK CAPACITY J `�
LEACHING FACILITY:(type) '' LL 1 (sue)
NO.OF BEDROOMS _PRIVATE WELL OR CUBLIC WATER
BUILDER OR OWNER '.41 /• ,'
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED: � 1-!
VARIANCE GRANTED: Yes No
i ? 1 1,r5,c j�
r.
f L-C•bti i
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=254021&seq=1 5/12/2014
SUII LO (' I
Ez_ 7o.. NLO �1L
SITE PLAN
Z
L'C'A2SE a
f •
TOP OF FOUNDATION EL. : �4.0 `�"ve` 6
Y.
� ••.• STLLV�
� °o �:°� ;�sTA� coves. ,PiSE.e/Ca✓E.4 M1N. 1'/, F IN � 8 i
ISH EE GRADE
9
•v a TO by/TN/N /2
Z9 a . /2 /�
IN MIN.G8. 49 Gg, Z COVER
Tb 0117J"iA/ /2"
2 COVER 1/8 3/8 WASHED STONE
E16� • J r + t� H I � 608'82 • • • • '`t '.'° NC 62lJlJNDyW9TFit'
' IN EL.�A' • ° ' ° ' 3/4 1 1/2 WASHED STONE ENCOUNTERFp 3
I 0/ 8 dN/ 6 SUMP . • . ,
4 ' LI Q U10 LEVEL ' • ' • • � ` oa ; ° .. 1 �!
6 EFF
00 DEPTH ° •° ° PERC T EST, RESULTS
PRECAST SEPTIC TANK WITH • : •' ° • ° • • Q PRECAST LEACHING PITS PERC RATE :
CAST IN PLACE INLET AND EL, �z,/ • - • • °• °° NO•; D;vE �'��,9. X E�FPTy WITNESSED BY
SIZE:
i BOARD OF HEALTH
OUTLET T 'S PER TITLE V 2 i
i000 G l L sT,✓ —DIAL OF STONE DATE : - - � - 90
SIZE .E $, LONG x 4'16," W I D E x 5'7" D E E P 1 ¢ Pervious _DIA ALL AROUND 7S•¢-9� f
Material
E l. sa•/ i
o I it
Bp�eM of �FST � �
PROFILE OF PROPOSE [ SEW -AGE SYSTEM
I SYSTEM DESIGNED BY THE TOWN OF _ L,4,Pi1/ST-4B/— REGULATIONS AND
STATE TITLE V FBR SUBSURFACE DISPOSAL OF SEWAGE . SCALE : 1/4% 1 ' 0 � q'
1 . ALL PIPES SHALL BE SCHEDULE 40 P.V.C . SEWER PIPE
2 ALL PIPES SHALL BE SLOPED 1/4 iTA
PER FOOT EXCEPT FOR ti xG � LIr v �
i 13 p p
THE FIRST Z FEET OUT OF THE 0 /8 WHICH SHAII BE LEVEL Z;115T N �
3. DESIGN FLOW 3 BEDROOMS AT 110 GALDAY pER BR 3= GAL/ DAY 3�. E �� e
33o X soy = 49S tJ N 7�,8 2
SEPTIC TANK SIZE GAl �-_ �
USE DODO GAL. Wl our GARBAGE DISPOSAL I L E A C H I N 6 SYSTEM : USE 4icf .4,r-P77'1 �,e6i:,oY7- '® �` T,�.✓,t- '
L��9CN!>iT N/ L l%vfE� STONE A�2D!/ND_ \
EFFECTIVE AREA : SIDE 2Tr�hX z. s= ZXr�Xsa'cX2,s = �7r Goo /c �, 8,L
BOTTOM TleZkh = 7rx2sX Ao 78 wo
TOTAL FLOW �7�f 78= s-�y GPD c '• i / 3g.
TOTAL REQ D FLOW 330 X 5-2 W/ QARBAGE DISPOSAL ,��Pi��� e� 7 -'
549- 33o 0
RESERVE FLOW Zi9 GAL! �Y IN RESERVE
,Z- 32
RUE RENC - PLANS
' E �
_ X
APPROVED BY . 3 f
BOARD Of HEALTH
I ( TOh/N 4F �ieNST.4BL.E
DATE : SITE AND SEWAGE PLAN
PROPERTY OWNER :
rc LDS/I�JdN/C�9 TiDNS X1,9Y
i FOR : N/Ci('!/L AS BU/L,Z/NG CO
f`a tiiih�lf� 7?/,QEE BEDROOM tINGLE FAMILY OWELI. ING
I
0A 1 E,4.���
� c ? ' ssTy. tlq OOYLE ENGINEERING ASSOCIATES, INCORPORATED
`` ' 3 Box 595— 530 Thomas B. Landers Road W. Falmouth, MA 02.574
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