HomeMy WebLinkAboutApp-Permit-ComplianceAP
a No.. llwj
FEEL=_S�
COMMONWEALM OF M ASSAC14USETTS f-icox
Board of Health, "/AV-kA0Qni , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION
PERMIT
Application for a Permit to Construct( ) Repair (0 Upgrade( ) Abandon( ) - ❑ Complete System .� Individual Components
Location AS
o
Owner's Name y Z
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
G
Designer's Name
Address
Address
Telephone#
Telephone#
/ o
Type of Building l/ t nGP 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 .2ao gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es oft place the tem in operation until a Certificate of�Compliance has b n issued by the Board of Health.
Signed Date e2
Inspections
No. Pfd /CJ ._„ oZ % J � - FEE
COMM® LT14 ®E MASSACHUSETTS
Board of Health, YA PP1OU�� , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Zf Individual Component(s) C] Complete System
The unde g eco hereby certify that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded( ), Abandoned ( )
by: 'IP,— : / j 7' '
at .% ::? /7 tJ .-4 EI n/ . 4-'/ .
�7r� .�
has been installe in actor aS ce -wtt a provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. % dated/ Xe % Approved Design Flow -- (gpd)
Installer X. k
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �l �jf�� �� —' / �� / y �y / FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, AF—M0U , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ranted to; Construct( RepairK ) Upgrade( ) Abandon( ) an individual sewage disposal system
at ./E, 7 c-.-, e;^, as described in the application for
Disposal System Construction Permit No / dated
j L/
Provided: Construction shall be completed within t rete years of the.,dge of this permit. local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date2' /,J Board of Health
f
No.: BOHDC-15-2954
Commonwealth of Massachusetts Fee
sss.00
Board of Health, Yarmouth, MA
APPLICATION FOR DI5POSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to: Repair-minor-Individual Component(s)
Location: 137 BEACON ST, SOUTH YARMOUTH, MA 02664 Owner:
BUCK JUDITH
Map/Parcel#: 098.60 137 BEACON ST
SOUTH YARMOUTH,MA 02664-1553
Phone:
Septic System Installer Designer
R.E. LARRIMORE
112 MAIN STREET HARWICH, MA
02645
Phone:
Type of Building:Dwelling Lot Size: 14,810.00 Acres
Dwelling-No.of Bedrooms.2 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixturos:
Plan Date: Number of Sheets:
Cafeteria:
Title: Revision Date:
Design Flow(min.required):220 gpd Calwlated design ilow:220 gpd Design flow provided:220 gpd
Description of Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR AEPAIR-REPLACE DBOX
7he undersigned agrees to insfall the above describetl Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further aarees not to olace in ooeration until a Certificate o/Comollance has been issued 6v the Boartl of Health.
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is hereby granted to;
R.E. LARRIMORE, 112 MAIN STREET, HARWICH, MA 02645
To perform: Repair-minor an individual sewage disposal system.
Owner: BUCK JUDITH
137 BEACON ST
SOUTH YARMOUTH,MA 02664-1853
Location: 137 BEACON ST, SOUTH YARMOUTH, MA 02664
Disposal System Construction Permit No.: BOHDC-15-2954 , Dated: August 10,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
CONDITIONS:
1. SEPTIC DISPOSAL-MINOR REPAIR- REPLACE DBOX TO EXISTING 1000 GAL SEPTIC TANK
AND LEACH PIT
�j � ,
V
Bruce G. Mur y, 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