HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1s^A� THE COMMONWEALTH OF MASSACHUSETTS FEE
�a X04 bC��✓"�°�'� BOARD OF HEALTH dL*j2?E3
OF
APPLICATION FOR DISPOS§Xt SYSTEM CONS UCTION PERMIT
Application for a Permit to Construct ( )Repair ( Upgrade ( )Abandon ( ) - omplete System ❑Individual Components
om Owner's Name
Pap/Parcel # Address
honeh,
Lot # C ! ILS;/�_ / //
Instiller' Designer's Name
�0 ddress jr� Address
Telephone # Telephone #
Type of Building: Q� Lot Size Sq. feet
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures ?rte
Design Flow (mi . re)Tuired) 30 gpd Calculated desi n flow 3 O gpd Desi n fl Ovided' gpd
Plan: Date ✓ 0Number of sheets Revision Die l�
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evalua�tiony 126 A.
DESCRIPTION OF EPAIRS OR ALT RATIONS
The undersigned grees to in tall the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu r rees not ace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ///C(/l;— 4
Ins ctions ' —
i
e
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
t r
---"- % 'aS `f -
No. �' THE CMMON�IVFp
Description of Work: ❑ Individual Component(s)
` W r —`
TH OF MASSACHUSETTS n�,F E i
_BOARD OF HEALTH�S v�% (," 12-15
OF CONJPUANCE
omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( Q, Repaired ( ), Upgraded ( ), Abandoned ( )
by: W I " Wl
{�
at s7 1��
has been installed in accordance withthe provision of 310 MR 15.00 (T le 5) and the approved design lans/as-built
plans relating to application No. 1 �_ dIS s dated S 5' / Sr Approved Design Flow (gpd)
Installer �� ``C4✓ e. lJ"`F L --
Designer: M Sp lv Inspector ( iXa' �Date
The issuance of this certificate shall not be construed as a gpdrantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMt_f.IANCE DEP APPROVED FORM 5/96
No. � S ^ �'� THE COMMONWEALTH OF MAS � T �< ' FEE
�jILb1�C t�2�, BOARD H(C
DISPOSAL SYSTEM CONSTRUCTIO>rPERMIT
Permission is hereby
disposal system at
in the application for Disl
,11 �r "
Provided: Cori,€r�Yidncls
Date
FORM 2 - DSCP;'
FORM 1255 (REV 5/96)
Construction Permit No.
an individual sewage
as described
/ - S Y"
leted 1 threeJ'el of'thf ,dAtd of his permit. All local conditions must be met.
Board of Health
DEP APPROVED FORM 5/96
H&W HOBBS& WARRENrM PUBLISHERS - BOSTON
No.:BOHDC-15-5625
Commonwealth of Massachusetts F�
so.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to: �lpgrade-Complete System
Location: 34 HARBOR RD,WEST YARMOUTH, MA 02673 Owner:
KENNEDY MICHAEL E
Mep/PerC¢I#: 029.108 KENNEDY RITA J
2282 ALBANY AVE
W HARTFORD,CT 06117
Phone:
Septic System Installer Designer
CARDINAL DAVID B.MASON,R.S.
32 RIDGETOP ROAD COTUIT, MA 4 GLACIER PATH
02635 EAST SANDWICH,MA 02537
Phone: 508-833-2177
5083641259
Type of Building:Dwelling Lot Size:9,583.00 Sq.Ft.
Dwelliog-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Futures:
Plau Date:06/03/2015 . Number of Sheets: 1 Cafeteria:
Tit1e:SITE AND SEWAGE PLAN 34 HARBOR ROAD Revision Date: ]0/09/2015
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design Flow provided:352 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:OS/20/2015
DAVID B.MASON,R.S.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,2-
500 GAL PRECAST CHAMBERS W/4'STONE:25'X 13'X 2'
The underslgned agrees W insfall the above deacribetl Intlividual Sewage Disposal System In accortlanee wiN the provisions of
TITLE 5 and fuMhet aarees not W olace in ooeration until a CertiFlcate of Comoliance has been issued bv the Board of Fleakh.
Signed Date
Inspections
� Commonwealth of Massachusetts
= Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ase.00
Peanission is herby granted to;
CARDINAL CONSTRUCTION,32 RIDGETOP ROAD, COTUIT,MA 02635
To perform:Upgrade an individual sewage disposal system.
Owner: KENNEDY MICHAEL E
KENNEDY RITA J
2282 ALBANY AVE
W HARTFORD,CT 06117
Location: 34 HARBOR RD,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-5625,Dated:November 06,2015
Provided:Constmction shall be completed within six mon[hs of the date of this permit. All local conditions must be met.
CONDITIONS:
1.SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK, DBOX,2-500 GAL PRECAST
CHAMBERS W/4'STONE:25'X 13'X 2'
2.MFC VARIANCE APPROVAL:A. SETBACK �
Bruce G. M hy, H, R.S.,CHO/Amy L.von Hone, R.S.,CHO
ealth Diredor/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:CARDINAL CONSTRUCTION
at:34 HARBOR RD,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-1S5625,dated ll/13/2015.
Installer:CARDINAL CONSTRUCTION
Address32 RIDGETOP ROAD COTUIT,MA 02635 Inspectoe AMY VON HONE,R.S.
' Designer.DAVID B.MASON,R.S.
Conditions
1.SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,2-500 GAL
PRECAST CHAMBERS W/4' STONE: 25'X 13' X 2'
2.MFC VARIANCE APPROVAL:A.SETBACK �j ,�/��„�
U�`t
Bruce G. Mu y, PH, R.S.,CHO/Amy L.von Hone, R.S.,CHO
Health Director/Assistant Health Director
The issaaoce of this permit shall not be construed as a guarantee that the system will funMion as designed.
BOH_Disposal_Construction_CofC.rpt