HomeMy WebLinkAboutApp-Permit-ComplianceNo. ` l� i 15 - 58 5,5 74FEE� '00
CkA 12-7
COMM® I.TII Of MZSSACIIUSETTS
Board of Health,,
%4R-i�1.OV'C1J MA.
APPLICATION F®I, DISPOSAL SYSTEM[ CONSTRUCTION// PERMIT
iA plication for a Permit to Construct( Repair(/4"U Abandon( - ❑ Complete System dd'lndividual Components
0
ocation — ,_� G
Owner's Name r,�,
Map/Parcel# .7 AVAddress
�1—
/
Lot#
Telephone#j--
A P� "'D
Installer'sName CAP":
rfi SE�p71C.SVCS.
Designer's Name
Address es -o od
Address
Telephone# o ate-
Telephone#
Type of Buildingf ,� K_ �i�, �.%s/ �� //mss+' Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
gpd Calculated design flow
Number of sheets
Design flow provided
Revision Date
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESC//RIPTION OF REPAIRS OR ALTERATIONSi�'/ar
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees two not to place the syste eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 4f Z41—
3
COMMONWEALTH M LTH OF ASSAC14USETTS 04 lzv- Z-, ss,
Board of Health, 1 ACMOVTµ , MA.
CERTIFICATE Of COMPLIANCE alb lose
Description of Work: "Invidual Component(s) ❑ Complete System
The undersi n d hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
at 70 ��� i° TF'�'rm -cg!
has been install
application No.
Installer
accorc)a ce with a pro�z ons of 3 MR 15.00 (Title 5) an the a proved design plans/as-built plans relating to
E' ,dated r� /� Approved Design Flow/ (gpd)
Designer: Inspector:/ Date: 4,
The issuance of this permit shall not be construed as a guaranteed that the system will function as designed.
C O O C. U O U; C, 00 JG COGC.I j01,. C O. C 0. 'J^ C(J J 0 1., C G C t, Q I C J01-0
No. 50"DC-15-5355 C..wE cob sem-Sva. FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM[ CONSTRUCTION. PERMIT
Permission is hereby granted to; Construct( ) Repair(`Upgrade( ) Abandon( ) an individual sewage disposal system
at fas describedn-the application for
Disposal System Constr} ction Permit No.X41- dated
Provided: Construction shall be completed within three -ars of the date of this pe�m`A,All local
al i nd'tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date/ �" f 7Board of Health `✓ ��
No.:BOHDGlS-5855
Commonwealth of Massachusetts Fee
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Application for a Permit to:Repair-minor-Individual Component(s)
Location: 7 BLYTHE TERR,WEST YARMOUTH, MA 02673 pµ.oer;
'� BONOSERNEST
i Map/Parcel#:067.41 BONOS PHYLLIS
299 CAMBRIDGE ST iJNIT 212
WINCHESTER,MA 02645-1890
Phone:
Septic System Installer Designer
J CAPE COD SEPTIC LOW& WELLER
350 ROUTE 28 WEST YARMOUTH, MA
02673
' Phone:
� 5087752825
i
�
IType of Building:Dwelling Lot Siu: 1Q019.00 Sq.Ft.
. DwelGng-No.of Bedrooms:3 Garbsge Grinder:
Other Type of Buildiog: No.of persons: Showers:
Other Fixtures:
Plao Date: 10/28/1981 Number of Sheets: 1
Cafeteria:
Title:SI1'E&SEWAGE PLAN LOT 13A BLYT1-IE TERRACE Revision Dah:
Design Flow(min.required):330 gpd Calculated design 11ow:330 gpd Desigo flow provided:373.6 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date otEvaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTTC DISPOSAL-MINOR REPAIR-REPLACE DBOX,REPAIR LEAKING
SEPTIC TANK PER INSPECTION REPpRT BY ENVIO-TECH DATED]0/28/2015
The undersigned agrees to Install the above tlescribed Intlividual Sewage Disposal SysMm In aecordance with the provislons of
TITLE 5 and further aareea not to olace in ooeration until a CertificaM of Comollanee has been issued hv the Board of Heakh.
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FeB
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
� CAPE COD SEPTIC SERVICES,350 ROUTE 28,WEST YARMOUTH, MA 02673
� To perform: Repair-minor an individual sewage disposal system.
� Owner: BONOS ERNEST
� BONOS PHYLLIS
� 299 CAMBRIDGE ST 11MT 2I2
. WINCHESTER,MA 02645-1890
iLocation:7 BLYTHE TERR, WEST YARMOUTH,MA 02673
! Disposal System Construction Permit No.: BOHDGIS-5855,Dated:November 17,2015
� Provided: ConsWc[ion shall be completed wi[hin six months of the da[e of this permi[. All bcal conditions must be met.
� CONDITIONS:
i1. SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX, REPAIR LEAKING SEPTIC TANK PER
i INSPECTION REPORT BY ENVIO-TECH DATED 10/28/2015
i �
Bruce G. rph , MPH, R.S.,CHO/Amy L.von Hone, R.S., CHO
� , Health Diredor/Assistant Health Diredor
The issuance of this permit shall not be conshued as a guarantee that the system will fuoction as designed.
� Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FeB
CERTIFICATE OF COMPLIANCE 555.00
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Repair-minor
by:CAPE COD SEPTIC SERVICES
at:7 BLYTHE TERR,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-1S5855,dated 11/18/2015.
Installer:CAPE COD SEPTIC SERVICES
Address350 ROUTE 28 WEST YARMOUTH,MA Inspector:AMY VON HONE,R.S.
02673
Designer:LOW&WELLER
Conditions
1.SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX,REPAII2 LEAKING SEPTIC TANK
PER INSPECTION REPORT BY ENVIO-TECH DATED 10/28 0,��
C
Bruce G. 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.
BOH_Disposal_Construdion_CofC.rpt