HomeMy WebLinkAboutApp-Permit-Compliancei� COM M®N . TMH i0F MASSACHUSETTS
Board of Health, YM0V114 , MA.
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APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION/ PE I1EP a 4 2015
Application for a Permit to Construct( ) Repair( ) Upgrade(�"
bandonO - ❑ Complete System di ua Ido r p�#cnL
Location `
f Owner's Name \A'
Map/Parcel# �' 3
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address 6 —6
J
GbA Address
Telephone# S�p(S
�j
Telephone#
Type of Building Lot Size
Dwelling - No. of Bedrooms _
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
sq. ft.
_ Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided god
Revision Date
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S2 kA Z) Qb 1.) \%
�A a c) Q k-sc>-K � \
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. 60P -DC -lam• ��3�
( FEE �. 1�
C®MM®N FYI'��T EALT14 OF MASSA'l..14�A�T SETTS 41%I,
Board of Health, yA•2M8e1N , MA
CERTIEICA E Of COMPHANC"
Description of Work: � Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired
by: ., YC
at -\,� n c y-,,— ,, oke ,- rok
c�-
Upgraded ( ) , Abandoned ( )
has been installed un a� orda�c�withfApprovi,'dtns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �� �� dated Approved Design Flow (gpd)
Installer sc--SA _
fr, car
Designer: Inspector: 4kittl Date:
The issuance of this permit shall not be construed as a guarauffee that the system will function as designed.
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lam" /�c COMMONWEALTH OF MASSACHUSETTS C&ftP7&
Board of Health, MAI M OUTA , MA.
If
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( /Upgrade ( ) Abandon( ) an individual sewage disposal system
at i L r� -t� ` Q �c� !Yc1t t-,/o.JA Pp as described in the application for
Disposal System Construction Permit No. ��`%�S- , dated
Provided: Construction shall be compjeddp.�woi tZ-
� e datetispe mit. All local conditions must be met..
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Date /Board o Health [�
No.: BOHDC-15-4436
Commonwealth of Massachusetts Fee
555.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Repair-minor-Individual Component(s)
� LocaHon: 9 ENTERPRISE RD,YARMOUTH PORT, MA 02675 Owner:
' SOUZA JOHN S TR
� Map/Parcel#: 093.32 JSS REALTY TRUST
� 56 KATHERINES LN
BREWSI'ER,MA 02631-2829
Phone:
Septic System Installer Designer
� 113 OLD YARMOUTH ROAD HYANNIS,
MA 02601
Phone:
Type of Budding:Other Type of Building Lot Size:9,583.00 Acres
Dwelling-No.of Bedrooms: Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fiatures:
Plan Dafe: Number of Sheets:
Cafeteria:
Title: Revision Date:
Design Flow(min.required): gpd Calculahd design ilow: gpd Desigo flow provided: gpd
Descriptioo of Soils:
Soil Evaluator Form No.: Name of Soil Evaluator. Date of Evaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-REPLACE H-10 DBOX WITH H-20 DBOX
TO EXISTING 1986 1500 GAL H-20 SEPTIC TANK AND 4 H-20 PRECAST LEACH GALLEYS W/3'STONE PER CONDITIONAL
INSPECTION REPORT DATED 08/27/2015 BY SEAN M.JONES
The untle�slgnetl agrees to Insfall the above tlescribetl Individual Sewage Dispoaal System in accordance with the provislona of
TITLE 5 and furfher aarees not W olace in ooeration until a Certificate of Comoliance has heen iasued bv fhe Boartl of Fleskh.
Signed Date
Inspections
• .
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FBB
DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
Permission is herby granted to;
To perform:Repair-minor an individual sewage disposa7 system.
' Owner: SOUZA JOFIN S TR
� JSS REALTY TRUST
�. 56 KATHERINES LN
BREWSTER,MA 02631-2829
Location:9 ENTERPRISE RD,YARMOUTH PORT,MA 02675
Disposal System Construction Permit No.: BOHDC-15-4436,Dated: September 11,2015
Provided: Cons[ruction shall be completed wi[hin six months of the date of this permit. All loca]wnditions mus[be met.
CONDITIONS:
1. SEPTIC DISPOSAL-MINOR REPAIR-REPLACE H-10 DBOX WITH H-20 DBOX TO EXISTING 1986 1500
GAL H-20 SEPTIC TANK AND 4 H-20 PRECAST LEACH GALLEYS W/3'STONE PER CONDITIONAL
INSPECTION REPORT DATED 08/27/2015 BY SEAN M.JONES
�V
Bruce G. Mu hy, PH, R.S., CHO/Amy L. von Hone, R.S., CHO
ealth 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 F�
CERTIFICATE OF COMPLIANCE 555.00
i
IDescription of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Repair-minor
by:
at:9 ENTERPRISE RD,YARMOUTH PORT,MA 02675
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 applicarion No.: BOHDC-15-4436,dated 09/14/2015.
Installer:
Address:113 OLD YARMOUTH ROAD HYANNIS, Inspector:AMY VON HONE,R.S.
MA 02601
Designer:
�V�
Bruce G. urp y,MPH, R.S., CHO/Amy L.von Hone, R.S., CHO
Health Diredor/Assistant Health Diredor
The issuance of this permit shall not be construed as a guarantee that the system will funMion as designed.
� BO H_Disposal_ConsVuction_CofC.rpt