HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0.601*t) C-/57 " V V 6///
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COMMONWEALTH OF MASSAC14USETTS 4-49 73yv
Board of Health, Ytiq=Mo Ln --A , MA. 041v I-rer
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT r
Application for a Permit to Construct( e a' Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location e
j'76- RdJ
Owner's Name
G � Q
Map/Parcel#
Address L
Lot#
Telephone#
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Installer's Name e�
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Designer's Name
Address !Io ybVUG?C--
/:Z/Lt,�fwlftAddress
Telephone# `jQ+� /;��T-6�'
7ep+a4_57-,3 7
Telephone#
Type of Building
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.
C.«/
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Re LcGam- I/ — W
gpd
The undersigned agreesVimnstheabove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no e sys in in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. ''' f���J FEE Cjlf i
COMMONWEALTH Of SSACHUSETTSCk4 �'�r� f� � Q7✓�`�
Board of Health, nLM4 MA.
CERTIFICATE Of COMPLIANCE
Description of Work: C3 Individual Component(s) Ll Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: /�]YZ'C 3DB WIND %21 V
at —%C" , .,., l -,e,-7 ,-
has been installedi�fcdit�ce v6itlthe r iouof 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated.. Al)� / SApproved Design Flow (gpd)
Installer ,-GIr .e'er-- ''r- fl ( Zo
Designer: Inspector: Date: A2 -.06-,%
The issuance of this permit shall not be construed as a guar/tee dat the system will function as designed.
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No. 60 x. Oe �D z vG t6, Glu v i rc ° FEE t _.
i �- -,?-2--) COMMONWEALTH OF MASSACHUSETTS c -*-973 Li`l
Board of Health, V,"M t - , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(- �pair( Upgrade( ) Abandon( ) an individual sewage disposal system
at 2 lac 9!6� 1?n> , 9� // as described in the application for
Disposal System Construction Permit No..•y� �with�in thr' dated
Id
Provided: Construction shall be ccOpkel&ees of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date oard of Health Ar
No.:BOHDC-15-4500 ��
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)
Location: 79 WEBSTER RD,WEST YARMOUTH, MA 02673 Owner:
GROHS GEORGE L
Map/Parcel#: 150.46.1 GROHS SUSANN
15021 LAKESIDE V[EW DR #2302
. FORT MYERS,FL 33919-8474
Phone:
Septic System Installer Designer
WIND RIVER
577 MAIN STREET, SUITE 110
HUDSON, MA 01749
Phone:
Type of Building:Dwelling Lot Size: 11Q207.00 Acres ��
Dwelling-No.of Bedrooms: Garbage Grinder:
Ot6er Type ofBuilding: No.of persons: Showers:
Other Fixtures:
Plao Date: Number of Sheets: Cafeteria:
Title: Revision Date:
Design Flow(mio.required): gpd Calculated design tlow: gpd Design flow provided: gpd
Description of Soils:
� Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluatiou:
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX TO EXISTING t000 GAL
SEPTIC TANK,2-30'X 2'X 1'TRENCHES
Tha undersigned agrees to inatall the above descrlbed Individual Sewage Disposal System in accordance withlhe provlslons of
TITLE 5 and further aarees not to olate in ooeratlon until a Cert'rfitafe of Comollance has heen issued bv the Boartl of Meskh.
Signed Date
Inspections
S
�
; Commonwealth of Massachusetts
Board of Health, Yarmouth� 1�1Li Fee
' DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
i
� Permission is hereby granted to;
WIND RIVER ENVIRONMENTAL, 577 MAIN STREET, SUITE 110, HUDSON, MA 01749
To perform: Repair-minor an individual sewage disposal system.
' Owner: GROHS GEORGE L
i
GROHSSUSANN
15021 LAKESIDE VIEW DR #2302
FORT MYERS,FL 33919-8474
Location: 79 WEBSTER RPAD, WEST YARMOUTH,MA 02673
� Disposal System Construction Permit No.: BOHDC-15-4500 ,Dated: October 06,2015
j Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
1
I CONDITIONS:
SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX TO EXISTING 1000 GAL SEPTIC TANK, 2-30'X 2'X 1'
TRENCHES
1. SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX TO EXISTING 1000 GAL SEPTIC TANK, 2-30'X 2'X
1'TRENCHES
U
Bruce G. Murp , PH, R.S., CHO/Amy L. von Hone, R.S., CHO
H alth Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
CERTIFICATE OF COMPLIANCE $55.00
a
Description of Work: Individual Component(s)
SThe undersigned hereby certify that the Sewage Disposal System; Repair-minor
; by: WIND RIVER ENVIRONMENTAL
at: 79 WEBSTER ROAD, 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.: BOHDC-15-4500, dated 10/06/2015.
�
�j Installer: WIND RIVER ENVIRONMENTAL
Address:577 MAIN STREET, SUITE 110 HUDSON, Inspector:AMY VON HONE R.S.
j MA 01749 '
� Designer:
C�
Bruce G. Murph , M H, 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.
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BOH_Disposal_Construction_CofC.rpt