HomeMy WebLinkAboutApp-Permit-ComplianceNo. BojAt)= 9-( 7-2-3 FEE � 55°.0V
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Board of Health, �� ROUTE 28r
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APPLICATION FOP DISPOSAL SM?ffM CTI®N PERMIT i
Application for a Permit to Construct( ) Repair( ) Upgradlx Abandon( ) - ❑ Complete SystemIndividual Components
Location'
Name 1 `ftm,1
Map/Parcel# -1 ---
1 ,
Address S
Lot# 2 0
Telephone#
Installer's Name
'1 l
Designer's Nam
Addressx
r
Address 4
Telephone#
Telephone# 7s
C� 4 i
Type of Buildin1 g L.ot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3� gpd Calculated+ design flow Design flow provided gpd
Plan: Date -2- � ' Number of sheets 1 Revision Date
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator �1. �-S Date of Evaluation b - 3
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agre install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o place the m. in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date -2- b - k S
Inspections
1��
No. -a - c. �z3 C®MMONW I.T14 Of MASSACHUSETTS .. � EECIL 4 lo 10
�
Board of Health, I JA L� 1 ,AL4. 0A
CERTIFICATE Of COMPLIANCE
Description of Work: U&dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),Zpgraded ( ), Abandoned ( )
by: �, 4
at
has been instalYe�dri�atxcrg'with/he'pvisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 4r-_ f! C- , dated _ -, _ f ---Approved Design Flow zk
T _(gpd)
Installer
Designer: ; Inspector: _
The issuance of this permit shall not be construed as a guarantee
Date:
No. 5041172=S7 , 12.7-3 6 i;FV 1 Q f t CrQ OA CGt NN5- FEE
COMMONWEALTH Off' MASSACHUSETTS 4LA-1r ®7th
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at G (1E ���� as described in the application for
Disposal System Construction Permit No. T„ 4,-1;, dated
i�tbree�yers of the date of this permit. All local conditions must be met.
Provided: Construction shall be completed �it
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadegown,MA Date - Board o2 I-fealth
No.:BOHDC-15-1223
Commonwealth of Massachusetts Fee
• sss.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Component(s)
Locallon: 95 DIANE AVE, SOUTH YARMOUTH, MA 02664 Owner:
COLLINS MARY K TAS
Map/Parce�k: 089.118 COLLINS JOSEPH P TRS
95 DIANE AVE
SOUTH YARMOUTH,MA 02664
Phone:
Septic System Installer Designer
R.J.BEVILACQUA STEPHEN IIAAS.PE
P.O. BOX 628 FORESTDALE, MA P.O.BOX 16
�2� SOUTH DENNIS,MA 02660
Phone: 508-362-8132
Type of Building:Dwelling Lot Siu: 16,553.00 Acres
Dwelliog-No.of Bedrooms:3 Garbage Grinder.
Other Type of Building: No.of persons: Showers:
Other Fiatures:
Plan Date:06/26/2015 Number of Sheets: 1 Cafeteria:
Title:SEPTTC SYSTEM DESIGN 95 DIANE AVENLJE Revision Date:
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Desigo 11ow provided:348 gpd
DescripNon of SoiIs:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator. Date of Evaluatioo:06/03/2015
STEPHEN HAAS,PE
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,2-500
GAL PRECAST CIiAMBERS W/4'STONE:25'X 12.8'X 2'
� The undersigned agrees to install the above tlescribetl Intlivitlual Sewage Disposal System in accortlance with the provisions of
TITLE 5 and fuMher aarees not to olace in ooeration until a Cert'rficate of Comolianee has been issued hv the Board of Heakh.
Signed Date
Inspec[ions
� Commonwealth of Massachusetts
� Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
Permission is herby granted to;
R.J. BEVILACQUA CONSTRUCTION, P.O. BOX 628, FORESTDALE, MA 02644
To perform:Upgrade an individual sewage disposal system.
Owner: COLLINS MARY K TRS
COLLINS JOSEPH P TRS
95 DIANE AVE
SOUTH YARMOUTH,MA 02664
Location:95 DIANE AVE,SOUTH YARMOUTH,MA 02664
Disposal System Conshuction Permit No.: BOHDGIS-1223,Dated:July 21,2015
Provided: Construc[ion shall be completed wi[hin six months of the date of this permi[. All local conditions must be met.
(_fG!
Bruce G. M hy, PH, R.S.,CHO/Amy L.von Hone, R.S.,CHO
ealth Diredor/Assistant Health Diredor
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FBe
CERTIFICATE OF COMPLIANCE a�.00
Description of Work: Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:R.J.BEVILACQUA CONSTRUCTION
at: 95 DIANE AVE, SOUTH YARMOUTH,MA 02664
Has been installed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDC-1S1223,dated 07/30/2015.
Installer:R.J.BEVILACQUA CONSTRUCTION
Address:P.O.BOX 628 FORESTDALE,MA 02644 Inspector:AMY VON HONE,R.S.
Designer. STEPHEN HAAS,PE
������
Bruce,G. M hy, MPH, R.S., CHO/Am L.von Hone, R.S.,CHO
v� Health Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
BOH_Disposal_Construdion_CofC.rpt