HomeMy WebLinkAboutApp-Permit-ComplianceNo +f)c 1 V Z'� _— FEE
COMMONWEALTH OF MASSACHUSETTS �2) (0
Board of Health, �+iLA-1 tJ , MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System -alg;i vidual Components
Location s y D oS S
Owner's Name %3 w 6 o" Ar
Map/Parcel#
Address S L{ D -LA& 2a-. y-
Lot#
Telephone# 77 , C9.&&- 0'140a
Installer's Name an l j %� ��7.4i� �Ci�dt
Designer's Name
Address 3
Address to O�
Telephone# S' cf.Coa
a
Telephone# s G� s `v q (j 3
Type of Building / Lot Size / 9 /,, 7 sq. ft.
Dwelling - No. of Bedrooms :3 Garbage grinder IV9
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) .��c> gpd Calculated design flow Design flow provided gpd
Plan: Date `'�� �---`l� Number of sheets Revision Date
Title
Description of Soil (s) a ,- ,
Soil Evaluator Form No. Name of Soil Evaluator // /refs ramal Date of Evaluation ' �� " AS
DESCRIPTION OF REPAIRS OR ALTERATIONS S -e e &e AJLi Z C
The undersigned a e to install the above describ Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t oto ce a ' until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
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No. 12sa � (,)Z�,„ "' d � "'��-�^. FEE v� 00 ®�'IM®�I�I,TII OF MASSACHUSETTS 4 Z5 -
Board of Health, Y�+QQ" , AIA. �
CERTIFICATE Of COMPLIANCE
Description of Work: .6Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (-T, Abandoned ( )
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at c
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /�s datedpproved Design Flow pd) A
Installer ! ! } / �. v:- J
?`�' % �� L%C�' �.C.:.. err
Designer: �1 ) k1 ✓; Z -C Inspector: Date:
The issuance of this permit shall not be construed as a guarantf6 that the system will function as designed.
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No. 60tA m (5-444:2 .. FEE . 00
,• e.— C® ®N LT1I Of MASSACHUSETTS CAI*
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.A Board of Health, _�'_ . Wrlin , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at C -C 11 Mr rl as described in the application for
Disposal System Construction Permit No. - , dated
Provided: Construction shall be completed within thrs� of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date __�-)_ —T'N -Board o ealt i
PIo.:BOHDC-15-4422
` Commonwealth of Massachusetts FBe
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permi[to:Upgrade- Individual Component(s)
Location: 54 DAVIS RD, SOUTH YARMOUTH, MA 02664 Owner:
OBRIEN BARBARA J LIFE EST
Map/Parcel#: 059.158 54 DAVIS RD
SOUTH YARMOUTH,MA 02664-4102
Phone:
Septic System Installer Designer
ELLIS BROTHERS PUNKHORN SERVICES
PO BOX 59 YARMOUTHPORT, MA p.0.BOX 483
02675 SOUTH DENNIS,MA 02660
Phone: 508-564-8379
Type ot Building:Dwelling Lot Size: 11,326.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:08/27/2015 Number of Sheets: 1 Cafeteria:
TitIe:PROPOSED SEPTTC DESIGN 54 DAVIS ROAD Revision Date:
Design Flow(min.required):330 gpd Calculated design Flow:330 gpd Design tlow provided:351 gpd
Description of SoiIs:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:08/26/2015
TERRY HAYES,R.S.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTfNG 1000 GAL SEPT[C TANK,DBOX,4
HIGH CAPACITY INFILTRATORS W/STONE:36'X 1 P X 10"
• The undersignetl agrees to insfall the above described Individual Sewage Disposal System in accordance wkh the provisions of
TITLE 5 antl further aarees not to olace in ooeration until a Certificate o(Cnmoliance has been iasued hv the Board of Heakh.
Signed Date
Inspectio�s
, Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
Permission is herby granted to;
ELLIS BROTHERS CONSTRUCTION, PO BOX 59,YARMOUTHPORT, MA 02675
To perform: Upgrade an individual sewage disposal system.
Owner: OBRIEN BARBARA J LIFE EST
54 DAVIS RD
SOUTH YARMOUTH,MA 02664-4102
Location: 54 DAVIS RD, SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDC-15-4422 ,Dated: September 22,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
CONDITIONS:
1. SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK, DBOX,4 HIGH CAPACITY
INFILTRATORS W/STONE:36'X 11'X 10"
2. BOH TO INSPECT SOIL REMOVAL
3.ZONE II MAXIMUM 3 BEDROOMS
Bruce G. Murp , H, R.S., CHO/Amy L.von Hone, R.S., CHO
alth Director/Assistant Health Diredor
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 Fee
CERTIFICATE OF COMPLIANCE sss.00
Description of Work: Individual Compooent(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:ELLIS BROTHERS CONSTRUCTION
at: 54 DAVIS RD, SOUTH YARMOUTH,MA 02664
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-15-4422,dated 10/08/2015.
Installer:ELLIS BROTHERS CONSTRUCTION
Address:PO BOX 59 YARMOUTHPORT,MA 02675 Inspector:AMY VON HONE,R.S.
Designer:P[INKHORN SERVICES
,� ��� ���
Bruce��. Murphy, MPH, R.S., CHO/Amy L.von Hone, R.S., CHO
Health Director/Assistant Health Diredor
The issuance of this permit shall not be wnstrued as a guarantee that the system will function as designed.
BO H_Disposa l_Construction_CofC.rpt