HomeMy WebLinkAboutApp-Permit-ComplianceNo.7y FEE rS� BOO
D MASSACHUSETTS
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'� Board of Health,-i�'tOl)ll-i , MA.
&'0-3'jP I TION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
a pplication for a Permit to Construct) Repair( ) Upgrade( ) Abandon( - ❑ Complete System X1,dividual Components
Location Jew S - F591Owner's
Name /'/ 7 ,1f C �/tl
Map/Parcel# 91,4 t -2l p � z
Address <� 57-
Lot#
Telephone#
Installer's NameN �l _ "
Designer's Name
Address -F�� &5y-� 41k,
Address 167-3 S UJ B l�
Telephone# c::
Telephone# vC _
Type of Building ��1 l7Z'-�71 l�G ✓Ic�C�c. - LotSize sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers (0, Cafeteria ( )
Other Fixtures /�j
Design Flow (min. required) f%�� gpd Calculated design flow —Y4Design flow provided gpd
Plan: Date l Number of sheets 1 Revision Date A1
Title sl—r Jj G�1 � ge- P&Ign � S/z1� J`�C f/l1%s �(� `J?.
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS f113Ati r>60—
P&PP �-,Z►yu13� ��� �'� �� /_�nr� �o �k�S�iii�-� 7�5�Iz�r�r�7/l 1 ��'
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The undersignMa�66esinstall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreesace a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date.
Inspections C.,00%G4 ��e �` S �!'- C C,
No. lJ� YC —(5-0-7 9 0
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inti/L � 74A FEE
COMMONWEALT14 Of MASSACHUSETT*.. sou ,Ya - � 3Z Z&
Board of Health, _ - yp�ouiy , MAO ,,q -z 1.4/
CERTIFICATE Of COMPLIANCE
Description of Work:ld"Individual Component(s) 0 Complete System J 4.4-X r t Ui�_
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ("'S, Abandoned ( )
by: P. S. 0 `1 f2 C- G— - - - - - -
at
L"IE
has been installed in accor
application No. /1;7 y
Installer P � S' N\► e,
V /�V
with the provisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
dated / - S — / ( . Approved Design Flow It - (gpd)
Designer: I M O (�� U"l Inspector: � � Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, 1 �� UTA% , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(
at 5"(, (?oUT& 6A
FEE �.00
ck* 3
Upgrade (-*� Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. 4"_�F / "dated
/_, 0,111K i S - 0 7E--Zf
Provided: Construction shall be completed within t >ne-reafs-of the
�date, of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. �Sulkin Co. Chadestown, MA , Date
y - Board of Health
No.:BOHDGIS-0780 ,
Commonwealth of Massachusetts Fee
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Applicatioo for a Permit to:Upgrade-Individual Component(s)
Location: 56 ROUTE 6A,YARMOUTH PORT, MA 02675 Owner:
HUGHESJOANN
Mep/ParC¢I#: 1212 56 ROUTE 6A
YARMOUTHPORT,MA 02675 -
Phone:
Septic System Installer Designer
P.J.NYBERG INC. JM O'REILLY&ASSOCIATES INC.
P.O. BOX 2009 DENNIS, MA 02638 P.O. BOX 1773
Phone: BREWSTER,MA 02631
(5081896-6601
Type of Building:Dwelling Lot Size:0.63 Acres
Dwelling-No.ot Bedrooms:4 Garbage Grinder:
Other Type of Building: No.of persons: Shawers:
Other Fixtures:
Plan Date: l ll14/2014 Number of Sheets: l
Cafeteria:
Tit1e:SITE&SEWAGE REPAIR DESIGN 56 MIAN STREET,YARMOUTH Revision Date: 11/21/2014
Design Flow(min.required):440 gpd Calculated design flow:440 gpd Design flow provided:455 gpd
Description ot Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:
DESCAIPTION OF REPA[RS OR ALTERATTONS:REPAIR-NEW 1500 GAL SEPTIC TANK/PUMP CHAMBER 2 COMPARTMENT
COMBINATION TANK PER INSPECTION REPORT 06/15/2012
The untlersi9ned agrees to InsWll the above described Intlividual Sewage Disposal System in accortlance with the provisions of
TITLE 5 antl(urther aarees not to olace in ooeration until a Certiticate of Comoliance has 6een issued 6v the Board of Heakh.
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FeB
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
P.J. NYBERG INC., P.O. BOX 2009, DENNIS, MA 02638
To perform: Upgrade an individual sewage disposal system.
Owner: HUGHESJOANN
56 ROUTE 6A
YARMOUTHPORT,MA 02675
Location: 56 ROUTE 6A,YARMOUTH PORT,MA 02675
Disposal System Conshuction Permit No.: BOHDC-15-0780,Dated: January O5,2015
Provided: ConstrucCion shall be completed within six months of the date of this permit. All local wndi[ions must be met.
Conditions
1. REPAIR-NEW I500 GAL SEPTIC TANK/PUMP CHAMBER 2 COMPARTMENT COMBINATION
TANK PER INSPECTION REPORT 06/I S/2012 (FRONT SYSTEM ONLY)
,
' vc�
Bruce . Murphy, 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.