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HomeMy WebLinkAboutApp-Permit-ComplianceA. No." 9044 YC-fS- S-2 5q Z5q COMMONWEALT14 Of M SSAC14USETTS Board of Health, YA':ldl�} , MA. FEE G3LGs���D APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PE*MUrALTI. DEPT. Application for a Permit to Construct( ) Repair �/Upgrade( ) Abandon( ) - ❑ Complete System U Individual Components Location 317 -k 3 C M 5� Owner's Name t L Us1ut�+1 Map/Parcel# Q (p 2-1 2 Address Pre, t� Lj. ICk,AAiR_, Lot# Telephone# -OF-tI32 . 0015 Installer's Name QLW 69 �� C , Designer's Name Address 2L( 6 W,e,5+e-Pr\ Address Telephone# IS -06-150q 056 Telephone# Type of Building Lot.Size Dwelling - No. of Bedrooms Other - Type of Building No. of persons 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 e sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS _ h%E' 1 l��Q-/SQL �Ka' -PA Fro .,,^ 14vse- TO gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to n¢ t� to :p'I epthe jsystem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed W: L_`�2.�Jll QkC r ,6i g:?iC Co. Tt-t `e- Date 10-2-3- k Inspections No. 13o N" D `i `.5251 FEE 066-1 00 COMMONWIFALT14 Of MASSACHUSETTS 0O70-zb Board of Health YAf=ffi Q UT -H MA. f CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) 0 Complete System S The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (4, Upgraded ( ), Abandoned ( ) by: l�ka l S, our 6:2. -Zi'1c at 3J-7+3)qC�//% 5 T� has been installed acc6r�r/, e wil rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. �-L f, , dated fD '� /�-/ Approved Design Flow (gpd) Installer 1'C3 'r B - oy-,r & , -T->hz CdfrtgSj0ff6)L. Oj Designer: Inspector: Dater " f The issuance of this permit shall not be construed as a guarpt a that the system will function as designed. 0003o., � c o o o c Q o o o o o o 0 c c c c c000uccocooco. oc0000000c���yyo uo(,p�000u0000u{'c�_0000000000c00000.�coou00000:�ocgq o_000c�c0000000�-0y0-0�000000000� No. V©i%bC"�J '��.� A • 4/' Ol) L t. 0, FEE 4 Vt� + 00 COMMONWEALTH Of MASSACIIUSETTS C, --k O07020 Board of Health, Y&g=M0UT-V+ , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair (V") Upgrade ( ) Abandon( ) an individual sewage disposal system at 7 17 -,1-31,e a 57- as described in the application for Disposal System Construction Permit No. dated -S Provided: Construction shall be Completed v tnthint ree years d this permit. All local con i ' s must be met. ,�- Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadeStown, MA Date le)' � � - 1.1I3oard of Health No.:BOHDGIS-5254 Commonwealth of Massachusetts F� sss.00 Board of Health, Yarmouth, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to:Repairvminor-Individaal Component(s) � Location: 317 CAMP ST,WEST YARMOUTH, MA 02673 Owner: IIARWICH ECUIvIENICAL CNCL FOR THE Map/Parcel#: 0622 HOMELESS POBOX86 WEST I-IARWICH,MA 02671 Phone: Septic System Installer Designer ROBERT B.OUR P.O. BOX 1539 HARWICH, MA 02643 Phone: Type of Buildiog:Dwelling Lot Siu:29,185.00 Acres Dwelling-No.of Bedrooms: Garbage Grinder. Other Type of Buildiog: No.of persons: Showers: Other Fixtures: Plan Date: Number of Sheets: Cahteria: Title: Revisioo Date: Desigo Flow(min.required): gpd Calculated design flow: gpd Design tlow provided: gpd Description of Soils: Soil Evaluator Form No.: Name of Soil Evaluator. � Date of Evaluation: DESCRIPT[ON OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-REPLACE ORANGEBURG PIPE BETWEEN FOiJNDATION AND SEPT[C TANK The undersigned agrees to inafall the above tlescribed Individual Sewage Disposal Syslem in accordance wMh the provisiona of TITLE 5 and further aarees not W olace in ooeration until a Cerliflcate of Comollance has heen issuetl 6v the 8oard of Fleakh. Signed Date Inspections i , , Commonwealth of Massachusetts Board of Health, Yarmouth, MA FeB DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00 Permission is herby granted to; ROBERT B.OUR COMPANY INC., P.O. BOX 1539, HARWICH, MA 02643 To perform:Repair-minor an individual sewage disposal system. Owner. HARWICH ECiJMENICAL CNCL FOR TI-IE HOMELESS POBOX86 WEST HARWICH,MA 02671 Location:317&319 CAMP ST, WEST YARMOUTH,MA 02673 Disposal System Construction Pemut No.: BOHDG1S5254,Dated:October 29,2015 Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met. CONDITIONS: 1. SEPTIC DISPOSAL-MINOR REPAIR-REPLACE ORANGEBURG PIPE BENVEEN FOUNDATION AND SEPTIC TANK V Cl�' Bruce G. y, MPH, R.S., CHO/Amy L. von Hone, R.S.,CHO Health Diredor/AssistaM Health Director 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 su.00 Description of Work: Individual Component(s) ; The undersigned hereby certify that the Sewage Disposal System; Repair-minor Iby:ROBERT B. OUR COMPANY INC. at:317&319 CAMP ST, WEST YARMOUTH,MA 02673 Has been installed in accordance with the provisions of 310 CMR I5.00(Title 5)and the approved design plans or as-built plaas relating to applicarion No.: BOHDC-1S5254,dated 10/29/2015. Installer:ROBERT B.OUR COMPANY INC. Address:P.O.BOX 1539 HARWICH,MA 02643 Inspector:AMY VON HONE,R.S. Designer: Condifions 1.SEPTIC DISPOSAL-MINOR REPAIR-REPLACE ORANGEBUR PIPE BETWEEN FOUNDATION AND SEPTIC TANK �� C�% Bruce G. Murp ,M H, 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_Dispasal_Construdion_CofC.rpt