HomeMy WebLinkAboutApp-Permit-Compliance`--Ngo q3)c - 1 -,57Js (p AV ; A e'e /-s /Id FEE � ®�
COMMONWEALTH OF MASSACHUSETTS dL-A 3 55 Te
Board of Health, YAiLMOl�T1� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade�ndon( ) - 0 Complete System-�vidual Components
Location V,% S1 j, r2-c'k,4$ :
er's Name
Map/Parcel# 4f7&
Address 13�
Lot#
Telephone#
Installer's Name (� 1 lb ry L' d
Designer's Name
AddressON �
Address
Telephone# I;c* j 6 a- 6al-7
Telephone#
Type of Building ��2g -j Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinderAllp
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
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS —�A
fir �1'`J� �✓ d s"�'� /�J�it�� C�'*� r^.' (,%
gpd
The undersigned agrees to install the above de&cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o pfa the syste' 0Y� �ofiiantil a Certificate off Compliance has been issued by the Board of Health.
Signed ie 2� ` j Date !/ �
Inspections
No. fw4- jc-( eJ —j f 8 (o EE J�
J •
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y�il l �'1 Ch i , AL4.
CERTIFICATE Of COMPLIANCE A/V-
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: L A 0 I'S t 3� 1� �= 1 0 r S 1
at a i! " v t! rg N Si ' Vt"l ' ,4. f11.
has been installed i ccor n e with the pro@sions of 310 CMR 15.00 (Title 5) and tV approved design plans/as-built plans relating to
application No. � dated /0 r/J i 47. Approved Design Flow (gpd)
Installer IS I I 1 3 i n i�-D ? h C7 7
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
_�`C OUOOC COO"�nnJ��O CC OOCC CO C-110f10f00'J000OO;:OOt�0000.0000 000111OO O 000CC CC0001)0.000 C O OOO O 00000000000�=000000A0004000000000q(�:O GO OL OOp 00000(
No. i�y�4b� 1�-S1 )p e:4-.-(rj bats/ FEE �-�ppP_- -5. 00
0 COMMONWEALTH Of MASSACHUSETTS
1
Board of Health, AfZWIOt)"fW- , MA. °W,
LL.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permissions is hereby granted to; Construct( ) Repair( ) Upgrade'( -y --`Abandon( ) an individual sewage disposal system
at t `� �� L) LL I- A tv - rz, �7 �� a `� '*described in the application for
Disposal System Construction Permit No. !�� L ,date- l
Provided: Construction shall be completed within th of the date of this pegn; t All localX(e ja idons must be met.
Date./O- - �~ -d f He
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, Tenn Date � � Board-� Health
No.:BOHDGIS-5186
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)
Locallon: 136 SULLIVAN RD,WEST YARMOUTH,MA 02673 Owner:
REDDY ADRIAN P
Map/Parcel#: 047.101 REDDY ROBERTA L
136 SULLIVAN RD
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
ELLIS BROTHERS
PO BOX 59 YARMOUTHPORT, MA
02675
Phone:
Type of Building:Dwelling Lot Size: 11,326.00 Acres
DwNliog-No.of Bedrooms: Garbage Grioder:
Ot6er Type of Building: No.of persons: S6owers:
Other Futures:
Plan Date: Number of Sheets: Cafeteria:
Title: Revision Date:
Design Flow(mio.required): gpd Calwlated design flow: gpd Desigo flow provided: gpd
Descripfioo of Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluatbo:
DESCRIPT[ON OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-EXISTING]000 GAL SEPTIC TANK,
PROPOSED DBOX WITH RISER AND NEW RISER ON EXISTING LEACH PIT
The undersignetl agraes to inatall the above described Indivldual Sewage Dlsposal System In accordance wkh the provislons of
TITLE 5 and further aareea not te olace in ooeration undl a Certificate of Comoliance has been issued bv the Board of MeaMh.
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
ELLIS BROTHERS CONSTRUCTION, PO BOX 59,YARMOUTHPORT, MA 02675
To perform:Repair-minor an individual sewage disposal system.
Owner: REDDY ADRIAN P
REDDY ROBERTA L
136 SULLNAN RD
WEST YARMOUTH,MA 02673
Location: 136 SULLIVAN RD, WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDG1S5186,Dated: October 30,2015
Provided: Construc[ion shall be completed within six months of the date of this peani[. All local conditions must be met.
CONDITIONS:
1. SEPTIC DISPOSAL-MINOR REPAIR-EXISTING 1000 GAL SEPTIC TANK, PROPOSED DBOX WITH RISER
AND NEW RISER ON EXISTING LEACH PIT
�'�V��
Bruce G. y,MPH, R.S.,CHO/Amy L.von Hone, R.S., CHO
% Heafth Director/Assistant Health Director
✓
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.