HomeMy WebLinkAboutApp-Permit-ComplianceZV I 6 LDTR - 6 5-60 5 9'1 (0
No. 1304'DC -r5- HE COMMONWEALTH OF MASSACHUSETTS FEE 6Y. C0
BOARD HEALTH dt4 [5-667
OF !
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components
^ Location n ,Owner's N m
�U1' VO no
G t
Map/Parcel # Address
Lot # —� etephpne #
Installer's D er's N
N4 �� min ame ter}
�Gt�al� .-4 ii rl is �i�n �f -�-PCk iYxv��.,l`�j'►11��`i- �/ J
dre s A dr ss
Telephone # Telephone #
Type of Building: t .,s i a -P (mg 1 Lot Size ;2T==Y Sq. feet"/
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (mi . req tired) gpd Calculated design flow gpd Design flow provided gpd
Plan: Date l S Number of sheets _ Revision Date, _
Title I
Description of Soil(s) C �C S� j
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 10,14J
e--,- .1 _ e--•_ ,al \ /-i 1^-, - f ...1 -- -_ .1 _ - % J,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees no placethe syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ox• Date
L
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
--- :511 ---------------------------------------------------
No.
-------- _---------- _-_No. C-'1'?'�►THE COMMONWEALTH OF MASSACHUSETTS FEE 5-5- q0
f y6 Lot) u 04 BOARD OF HEALTH cjz--# 1S 3(0-?
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) J�a plete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (, Repaired ( ), Upgraded ( ), Abandoned ( )
by: F'l',l 1 CI Ul5 14 Cr -
at lC) eitiEUC1 ffillJ�')
has been installed in accordance with th provisions of 310 CMV, 15.00 (Title 5) and the approved design laWas-built
plans relating to application No. dated , , r / Approved Design Flow (gpd)
Installer P 00 CFD
Designer: Dr)U)A l_ CL tole Ff)G Inspector (J4' Date
j f
The issuance of this certificate shall not b& construed as a arantee that :the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 60ODC`li`P-THl!E''COMMONWEALTH OF � MASSACHUSETTS FEE z' 06
lS y'b Uiq-D!Y)DI,tj:D4 BOARD OF HEALTH r—k#"153(a
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct (i Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at as described
i s z /
in the application for Disposal System Construction Permit No. -- ,dated
Provided: Construction shall be completed within three years of the date o7thi permit. All lodal conditions must be met.
Date ..1� Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS & WARREN T11 PUBLISHERS - BOSTON
No.: BOHDC-15-2311
' Commonwealth of Massachusetts F�
sss.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
Location: 70 HEMEON DR,WEST YARMOUTH, MA 02673 Owner:
MILLER ROBERT F TRS �.
Map/Parcel#: 038.86 MILLER VIOLA E TRS
21 WELLESLEY AVE
NEEDHAM,MA 021941821 . .
Phone:
SepHc System Installer Designer
PKM CONTRACTORS, DOWN CAPE ENGINEERING.INC.
P.O. BOX 175 EAST DENNIS, MA 939 ROUTE 6A
02641 YARMOUTHPORT,MA 02675
Phone: (508)362-4541
Type of Buildiog:Dwelling Lot Size: 16,988.40 Acres
DwelGng-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persoos: Showers:
OMer Fixtures: ��
PlaoDate:04/2U2015 NumberotSheets: l Cafeteria: �.
Title:TITLE 5 SITE PLAN 70 I-�MEON DRIVE Revision Date:OS/08/2015 .
Design Flow(roin.required):330 gpd Calculated design flow:330 gpd Design Flow provided:349 gpd I
, Description of Soi1s:SEE PLAN �
i
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:03/25/2015 ;I
DANIEL GONSALVES,SE '��,
c
DESCRIPTION OF REPAIRS OR ALTERATIONS:NEW- I500 GAL SEPTIC TANK,DBOX,2-500 GAL PRECAST CHAMBERS W/4'
STONE:25'X 12.83'X 2'
The undersigned agrees to inshll the above described Individual Sewage Disposal System in aeeortlanee with the provisiona of
TITLE 5 and further aareas not W olace in oceratlon untll a CertlFlcate of Comolianee has been issued bv the Board of HeaMh. .
Signed Date
Inspections
.
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
PKM CONTRACTORS, INC., P.O. BOX 175, EAST DENNIS, MA 02641
To perform:Upgrade an individual sewage disposal system.
Owner: I�9LLER ROBERT F TRS
MILLER VIOLA E TRS
21 WELLESLEY AVE
NEEDIIAM,MA 02194-1821 �
Location: 70 HEMEON DR,WEST YARMOUTH,MA 02673
Disposal System Coastruction Permit No.: BOHDC-1�2311 ,Dated:Juue Ol,2015
Provided: Construc[ion shall be completed within six months of the date of this permit. All local conditions must be met.
�
Bruce G. urphy,MPH, R.S., CHO/Amy L.von Hone, R.S., CHO .
Health Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarantee that the system will funMion as designed.
Commonwealth of Massachusetts I'�
Board of Health, Yarmouth, MA F�
CERTIFICATE OF COMPLIANCE ass.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:PKM CONTRACTORS,INC.
at:90 HEMEON DR,WEST YARMOUTH,MA 02673
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.: BOHDG1S2311,dated OS/12/2015.
Insbller:PKM CONTRACTORS,INC.
Address:P.O.BOX 175 EAST DENNIS,MA 02641 Inspector:AMY VON HONE,R.S.
Designer:DOWN CAPE ENGINEERING,INC.
�vW
Bruce G. rph ,MPH, R.S.,CHO/Amy L.wn Hone, R.S.,CHO �'
Health Director/Assistant Health Director
The issuance of this permit shall nat be construed as a gua ntee that the system will function as designed.
BOH_Disposal_Construction_CofC.rpt