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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 41)c�f' FEE 55. 00 7� C®NINI®N I~%I 0 ASS 04USETTS Board of Health, YAa Q l_ TVA , MA. APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT Application for a Permit to Construct( ) Repair(<Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location Owner's Name 11' j Cka-e- M , L Map/Parcel# Address V#Z Lot# Telephone# 617- 01- 7700 Installer's Name- 8l1 Designer's Name Address Z &. Address Telephone# �� Q - JT' Telephone# Type of Building Te- 1 deA Lot Size Dwelling - No. of Bedrooms Other - Type of Building No. of persons Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soils) gpd Calculated design flow Number of sheets sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Ee f ©E�g� P i`Pe /-'( o M -- — -- a .1-.-- I.�- e . _._ _.r1 11 gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to no to place thesystemin operation until a Certificate of Compliance has been issued by the Board of Health. Signed l�e �ierr43,&or (9.-Tk e- Date Inspections No. t 4�C� —403 If FEE `S�.00 COMMONWEALTH OF MASSACHUSETTS eG�-DUb,y/0 Board of Health, VAc Q -N O tT , MA.�� 1 CERTIFICATE OF COMPLIANCE41 N Description of Work: t Individual Component(s) ❑ Complete System ��: c The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired , Upgraded ( ), Abandoned ( ) by: 1--c� ✓3,,8yr at l_ 1_ tib t� - - - has been installed in accordance with the rovisions of 310_ CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application ppNo. / � / / C dated 'L /- / . Approved Design Flow "--[� (gpd) Installer KO , 0 v r 1 L 9-09— (L 09- Designer: .�--- Inspector�ethat - J( L Date: The issuance of this permit shall not be construed as a guarhe system will function as designed. -7 S- COMMONWEALTH Of MASSACHUSETTS Board of Health, � � 10 y � T4 , MA. ,g DISPOSAL SYSTEM ST CONSTRUCTION PERMIT FEE (( . 40 (J `�T i3OG� ! V Permission is hereby granted to; Construct( ) Repair(V� Upgrade( ) Abandon( ) an individual sewage disposal system r at L) l✓- 6.h IZI-as described in the application for Disposal System Construction Permit No. / / S , dated' F / /'. Provided: Construction shall be completed within thre�yeafs of the date of this per it. local conditio s must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Cu* atee % `'Board of Health I A . � i No.:BOHDGIS-4088 Commonwealth of Massachusetts FeB 555.00 Board of Health, Yarmouth, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to:Repair-minor-Individual Component(s) � Location: 4 EBB RD,YARMOUTH, MA 02675 Owner: � MCNALLY F MICHAEL Map/Parcel#: 137.42 11 BRAE RD QUINCY,MA 02169 Phone: Septic System Installer Designer ROBERT B.OUR � P.O. BOX 1539 HARWICH, MA 02643 Pbone: Type of Building:Dwelling Lot Size:8,712.00 Acres DwelGng-Na oCBedrooms: Garbage Grinder: .. Other Type of Building: No.of persons: Showers: Other Fizturcs: �� Plao Date: Number ot Sheets: Cafeteria: � Title: Revision Date: � Design Flow(min.required): gpd Calculahd design 11ow: gpd Desigo flow provided: gpd Description of Soils: Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluafioo: , DESCRIPTTON OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-REPLACE ORANGEBURG PIPE BETWEEN FOi7NDATTON AND CESSPOOL The untle�signetl agrees to install the above descAbed Indlvidual Sewage Disposal SysMm in aeeortlanee wkh the provislons of TITLE 5 antl furfher aarees not to olate in ooeration untll a CertlFlcafe of Comollance has heen issued bv the Boartl of Health. Signed Date Inspections � . , . Commonwealth of Massachusetts Board of Health, Yarmouth, MA F� DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00 Permission is herby granted to; ' ROBERT B. OUR COMPANY INC., P.O. BOX 1539, HARWICH, MA 02643 To perform: Repair-minor an individual sewage disposal system. � Owner: MCNALLY F MICHAEL 11 BRAE RD . QUINCY,MA 02169 i i Location: 4 EBB RD, YARMOUTH,MA 02675 Disposal System Construction Permit No.: BOHDC-15-4088 , Dated: August 21,2015 � Provided: Construction shall be completed within six months of the date of this permit. AI►local conditions must be met. i CONDITIONS: i 1. SEPTIC DISPOSAL-MINOR REPAIR-REPLACE ORANGEBURG PIPE BETWEEN � FOUNDATION AND CESSPOOL ! ��' vc� Bruce G. Murphy, M H, .S., CHO/Amy L. von Hone, R.S., CHO Ith Director/Assistant Health Director The issuance of this permit shall not be construed as a guarantee that the system will function as designed. I Commonwealth of Massachusetts Board of Health, Yarmouth, MA Fee CERTIFICATE OF COMPLIANCE $55.00 Description of Work: Individual Component(s) The undersigned hereby certify that the Sewage Disposal System; Repair-minor I � by:ROBERT B.OUR COMPANY INC. at:4 EBB RD,YARMOUTH,MA 02675 Has been installed in accwdance with the provisions of 310 CMR 15.00(Title 5)and the approved design plans or as-built plans relating to application No.: BOHDC-1S4088,dated 08/25/2015. Installer:ROBERT B. OUR COMPANY INC. Address:P.O.BOX 1539 HARWICH,MA 02643 Inspector:AMY VON HONE,R.S. Designer: ��C��r �� Bruce G. Mucph , MPH, R.S., CHO/Amy L.von Hone, R.S.,CHO �j Health Director/Assistant Health Diredor The issuance of this permit shall not be construed as a guarantee that the system will funMion as designed. BOH_Dispasal_Constructlon_CofC.rpt