HomeMy WebLinkAboutApp-Permit-Complianceu No'r; �(✓tt�C��S c'/ %�� �< FEE
COMMONWEALTH LTH ®F MASSACHUSETTS
Board of Health, )/ tV l i , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ' bandon() - C]Complete System Z<dividual Components
Location 41,3
not) RQ �P__ L
Owner's Name
Map/Parcel#
Q (O . 2-
Address L13 mo n rZo c-
Lot#
Telephone# g' - 760
Installer's Name
1(g�.
Designer's Name c—,
Address Vo Pr
0
Address
Telephone#
7 d6
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
gpd
The undersigned agrees tQAmtaH the ab ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to I e cyst operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ Date
Inspections
No. Bo4 DC. q6-- 075'2— 5'2— q �A� T FEE —r 0
t)
COMMONWEALTH OF MASSACHUSETTS A_135 1O'
ell -
Board of Health, �Y�A� 8 U-11+ , MA. �l ,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( , Repaired ( ), Upgraded ( ), Abandoned ( )
by:LillZ3'' t,il/ D P-1 VOL I�FAJYl iZ O>Vl4omit- L LC -
at nh n 0 G. 1 /✓
has been installed
application No.
Installer
of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
,�5Approved Design Flow (gpd)
Designer: '^"-- Inspector:,
Date: 7:•�
The issuance of this permit shall not be construed as a guarantedthat the system will function as designed.
�:^'-�_.i� �.r.r:..-�,"., r.., -, r- �..,/i�_^.�...'�c�C'r,_l.lL-.��rn^(::_r.�n,l �7 r.nC�:,n::l��}O.ni-L`C'_gip^n.<'.U�.,�.Or::^..cwv_CCC�n G'OLi.'JJC::CC,.;�JUQ�f�:'C,'�32i.^.c^JJOCn�I•; :�C.:'� �.�0-C��.Ct, :r,�.
No. Wi M iD je4 VE-�%7. GN 0 R '0A)44� -L1 %.:...Q. FEE
/ S Y /� COMl"ll®1�� 1'i' LTH OF MASSACHUSETTS
Board of Health, YA etW aunt 1111M.
➢DISE®SAI. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(.Oj_ Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within &4zt 'CYf'tlle date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date 7 Board bf'Fiealth i v
No.:BOHDC-15-0752
Commonwealth of Massachusetts Fee
ass.oa
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Application for a Permit to: Repair-minor-Individual Component(s)
Location:43 MONROE LN,WEST YARMOUTH, MA 02673 Owner:
TUCKER JEAN F
Map/Parcel#: 06722 43 MONROE LANE
WEST YARMOUTH,MA 02673
Phone:
Septic System Iostaller Designer
WIND RIVER
577 MAIN STREET, SUITE 110
HUDSON, MA 01749
Phone:
Type otBuilding:Dwelling Lot Size: 1Q454.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder.
Other Type of Buildiog: No.of persoos: Showers:
Other Fixtures:
Plan Date: Number of Sheets:
Cafeterie:
Title: Revision Date:
Desigu Flow(mio.required):330 gpd Calculated desigo flow:330 gpd Desigo flow provided:330 gpd
Descripfion of Soils:
Soil Evaluator Form No.: Name otSoil Evaluator. Date of Evaluation:�
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPT[C DISPOSAL-MINOR REPAIR-REPLACE OUTLET TEE FILTER TO
EXISTING]000 GAL SEPTIC TANK AND 4'LEACH PIT W/3'STONE
The undersigned agrees to Install the above tleseribed Intlivitlual Sewage Diaposal System in accortlanee wMh the provisions of
TITLE 5 antl further aarees nM[o olace In ooeration untll a Certlficate M Comoliance has been Issuetl hv the BoaM of Fleakh.
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
WIND RIVER ENVIRONMENTAL, 577 MAIN STREET,SUITE 110, HUDSON, MA 01749
To perform:Repair-minor an individual sewage disposal system.
Owner: TUCKER JEAN F
43 MONROE LANE
WEST YARMOUTH,MA 02673
Location:43 MONROE LN, WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-0752 ,Dated:July 21,2015
Provided: Conshvction shall be comple[ed wi[hin six mon[hs of the date of this permi[. All local conditions must be met.
Conditions
I. MINOR REPAIR-REPLACE OUTLET TEE FILTER TO EXISTING 1000 GAL SEPTIC TANKAND 4'
LEACH PTl W/3'STONE
V C�/
Bruce G. rp ,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 function as designed.
Commonwealth of Massachusetts
' Board of Health, Yarmouth, MA F88
CERTIFICATE OF COMPLIANCE sss.00
Description of Work:Individual Component(s)
, The undersigned hereby certify that the Sewage Disposal System; Repairvminor
by: WIND RIVER ENVIRONMENTAL
at:43 MONROE LN,WEST YARMOUTH,MA 02673
Has been installed'm accordance with the provisions of 310 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDG1S0752,dated 07/21/2015.
Installer: WIND RIVER ENVIRONMENTAL
Address:577 MAIN STREET,SUITE 110 HUDSON, Inspector:AMY VON HONE,R.S.
MA 01749
Designer.
Conditions
1.MINOR REPAIR-REPLACE OUTLET TEE FILTER TO EXIS G 1000 GAL SEPTIC TANK
AND 4'LEACH PIT W/3' STONE i ���G��, ,/�
, �;,�,7
Bruce G. rphy,MPH, R.S., CHO/Amy L.von Hone, R.S., CHO
Health Director/Assistant Health Diredor
The issuance of this permit shall not be construed as a guarantee that the system will Function as designed.
BO H_Disposal_Construdion_CofC.rpt