HomeMy WebLinkAboutApp-Permit-ComplianceNo. e'41-bG 46-- ZI `/8 $S , 60 &P% /, -04J(o%�-- FEE
vlz-�-�9 il
� ��c �` ��
COMMONWEALTH OF MASSACHUSETTS
j
Board of Health, Y49#10
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon( ) - omplete System ❑ Individual Components
Location , A) ee
�A1L.
Owner's Name
Map/Parcel# g% a -aa
/ p� j
Address `
Lot#
Telephone#
Installer's Name
Designer's Name
Address/goAddress
`
Telephone# `��..�
�.� f`�
Telephone#
Type of Building.
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) i�� gpd Calculated design flow 3 Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) -d4-AX- A2 -41-A-4
IF
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAJARS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr_exs to not to place the system in operatio til a Certificate of Compliance has been issued by the Board of Health.
Signed Date
No. P� nC-( 2A4.3 /4 ,f %FEE`J 'QU
.
--/U
COMMONWEALTH OF MASSACHUSETTS o* e� 4'* eek
Board of Health, YJ�?2AV1 o Vrjj , MA. dq \
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Xandoned ( )
by: grit r _ t1G./ 4./ �� •
has been instalfe'd`IdEeMddn%&e wttR- hTf Frokisions of 310 CMR 15.00 (Title 5) s.. and thea roved design plans/as-built plans relating to
application No. ��� fD L dated 4 - `/ �.Approved Design Flow (gpd)
Installer �� L� �� 1ai� .ar .� i: 1 e�rr,
,-�.--
Desi nen/ f y Iris�etor ! ti=� df' Date
g
The issuance of this permit hall not be co strued as a guar tee that the system will function as designed
_ �, . c.. _ y. _
cec�o`y,,�c�c.e<...,./:.,�ao.c.. .,:.;�ce. �:-.. ,t. �c _��o. c.,.��..,,.eoe..cc,.c.�.,nuc.. r.eoce000000000e000c oc.
No. O C' �� �C S t✓U t tTS + /"t �F+1�7'! FEE d 00
COMMONWEALTH OF MASSACHUSETTS ck--0897°7
Board of Health, y n jml MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit o. K i% to , dated
Provided:. Construction shall be completed within thY444Za"-of-the date of this permit? All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ./ �B03rQ Oflth / J J ` /X f ldgjf
No.:BOHDC-15-2148
. Commonwealth of Massachusetts Fee
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
LocaHon: 146 ROUTE 6A,YARMOUTH PORT, MA 02675 Owner:
GROBE FRED NORTHRUP TR
Map/Parcel#: 122.35 THE F N GROBE REVOCABLE LIV[NG TRUST
146 MAIN ST
YARMOUTH PORT,MA 02675-1712
Phone:
Septic System Installer Designer
CHASE&MERCHANT DOWN CAPE ENGINEERING.INC.
P.O. BOX 5 DENNISPORT, MA 02639 939 ROUTE 6a
Phone: YARMOUTHPORT,MA 02675
(508)362-4541
Type of Building:Dwelling . Lot Size: 1Q890.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Futures:
PlaoDate:01/2I/2015 NumberofSheets: l Cafeteria:
Tide:T[TLE 5 SITE PLAN 146 ROUT'E 6A Revision Date:
Design Flow(min.required):330 gpd Calculated design tlow:330 gpd Design 11ow provided:349 gpd
DescripHon of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluaror. Date of Evaluation:Ol/07/2015
DANIEL GONSALVES,SE
DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR- 1500 GAL POLYTANK,DBOX, l6 HIGH CAPACITY H-20
INFILTRATOR UNITS W/OUT STONE IN F[ELD CONFIGURATION:2 ROWS OF 6 UNITS, 1 ROW OF 4 UNITS
, The undersigned agrees to install the above descNbed Individual Sewage Disposal System in aecortlance wkh the provisions of
TITLE 5 and fuRher aarees not to olace in ooerotion until a CertHicate of Comoliance has been issued bv the 8oard of Flealth.
Signed Date
Inspections
Commonwealth of Massachusetts
� Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
i
�
� Permission is herby granted to;
CHASE&MERCHANT INC., P.O. BOX 5, DENNISPORT, MA 02639
To perform:Upgrade an individual sewage disposa7 system.
Owner: GROBE FRED NORTHRW 7R
THE F N GROBE REVOCABLE LIVING 7RUST
146 MAIN ST
� YARMOUTH PORT,MA 02675-1712
�
Location: 146 ROUTE 6A, YARMOUTH PORT,MA 02675
Disposa7 System Construction Permit No.: BOHDC-1S2148,Dated:June 09,2015
' Provided: Conslruction shall be comple[ed within six months of the date of this permit. All local conditions must be met.
Conditions
1. REPAIR-I500 GAL POLYTANK, DBOX, 16 HIGH CAPACITY H-20 INFILTRATOR UNITS W/OUT
STONE INFIELD CONFIGURATION:2 ROWS OF 6 UNITS, 1 ROW OF 4 UNTIS
2. MFC YARIANCES: 1. SETBACKS TO FOUNDATION AND PROPERTY LINES
3. BOH TO INSPECT SOIL REMOVAL
Bruce G u hy, 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.
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
CERTIFICATE OF COMPLIANCE sss.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:CHASE&MERCHANT INC.
at: 146 ROUTE 6A,YARMOUTH PORT,MA 02675
Has been installed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved
design plans or as-built plaas relating to applicarion No.: BOHDC-15-2148,dated 09/23/2015.
Installer:CHASE&MERCHANT INC.
Address:P.O. BOX 5 DENNISPORT,MA 02639 Inspector:AMY VON HONE,R.S.
Designer. DOWN CAPE ENGINEERING, INC.
Conditions
1.REPAIR- 1500 GAL POLYTANK,DBOX, 16 ffiGH CAPACITY H-20 INFILTRATOR UNITS
W/OUT STONE IN FIELD CONFIGURATION: 2 ROWS OF 6 UNITS, 1 ROW OF 4 UNITS
2.MFC VARIANCES: 1.SETBACKS TO FOUNDATION AND PROPERTY LINES
3.BOH TO INSPECT SOIL REMOVAL n �C� /n'G��
c>S/� U=�
Bruce G. Murp y,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 fuuction as designed.
BOH_Disposal_Construdion_CofC.rpt