HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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� /), � 0 Board of Health, �A-R 00 i , MA.
et/� �PLICATION FOP, DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
AppliEanon fora ermit to Construct( ) Repair( ) UpgradeV-AbandonO - Complete System ❑ Individual Components
Location
t
Owner's Namei
Map/Parcel# ! 110 b?l
Address /
Lot#
Telephone#
Installer's Name ��
_ • Designer's Name
Address
l� Address e' le " VO / f
Telephone# v--' '
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
9
No. of persons
Lot Size � ��� sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 d gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrM to not to place the system in operad.o til a Certificate of Co , pliance has been issued by the Board of Health.
Signed ; �� Date
rg' AIM/
COMMONWEALT14 Of MASSACHUSETTS,,?. Ao�� ck,*pe (a`�
Board of Health, YAAZ.MOL7iY!
"_ ... CERTIFICATE Of COMPLIANCE
\ Description of Work: ❑ Individual Component(s) �omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded�Abandoned ( )
at i 1�! .
has been installed in • c c1'an( tvithih@ p visions of 31� MR 15.00 (Title 5) and the; proved design plans/as-built plans relating to
application No. --;15<!a, dated C– /0 ,r Approved Design Flow ---110(gpd)
Installer 17
Designer: l�-r ^ t' A Inspector: 1 Date: f �a%
The issuance of this permit shall not be construed as a guar tee at the system will function`as designed.
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o-cogaoLU-O-o O-a-o.o00o
No. 60 41b `+`q
FEE5 c!i Q .
COMMONWEALTH OF MASSAC14USETTS
Board of Health, *a1 Q urlN , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted too; Construct( ) Repair( ) Upgrade (, j ,Abandon( ) an individual sewage disposal system
at </ (�k.. �'�P,/i1. �JA�-� ���Y� as described in the application for
Disposal System Construction Permit No. 14--1111-1 , datedS—%Q
i -r-2
Provided: Construction shall be completed wl�Cn tdzx r�7C3s of the date of this permit.(All local condi ' s must be met.
Form 1255 Rev. 5/99/6 A.M. Sulkin Co. Charlestown, MA Date / Board ofHealth 1
S.A Z� Y.r //Ar-�
No.: BOHDC-15-2470
� Commonwealth of Massachusetts Fee
E55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
Location: 11 CAPE ISLE DR, SOUTH YARMOUTH, MA 02664 Owner:
KOSKI KARL A
Map/Parcel#: 019.81 KOSKI CLAIRE M
ll CAPE ISLE DR
SOUTH YARMOUTH,MA 02664-51l0
Phone:
Septic System Installer Designer
CHASE&MERCHANT OCEANSIDE SEPTIC
P.O. BOX 5 DENNISPORT, MA 02639 P.O.BOX 201
Phone: BREWSTER,MA 02631
508-896-1513
Type of Building:Dwelling Lot Size:8,712.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
0t6er Type of Building: No.of persons: Showers:
Other Fiaturos:
Plan Date:OS/08/2015 Number of Sheets: 1 Cafeteria:
Title:PROPOSED SEWAGE DISPOSAI,SYSTEM 11 CAPE ISLE DRIVE Revision Date:07/28/2015
Design Flow(min.required):330 gpd Calculated desigo flow:330 gpd Design flow provided:350 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:04/30/2015
LINDA PINTO,PE
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-.REPAIR•PROPOSED 1500 GAL SEPTIC TANK,650 GAL
PUMP CI-IAMBER,DBOX,20 ADS ARC36LP UNITS W/OUT STONE:25'X 113'X 33"
: The undenigned agreea W install the above descrlbed Indivldual Sewage Disposal System in aecortlanee wkh fhe provisions of
TITLE 5 and fuMer aarees not to olace in ooeretion until a Car[ificate of Comolianee has been issued bv the Boartl of Heskh.
Signed Date
Inspections
� Commonwealth of Massachusetts
. Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is hereby granted to;
CHASE &MERCHANT INC., P.O. BOX 5, DENNISPORT, MA 02639
To perform: Upgrade an individual sewage disposal system.
Owner. KOSKI KARL A
KOSKI CLAIRE M
11 CAPE ISLE DR
SOUTH YARMOUTH,MA 02664-5110
Location: 11 CAPE ISLE DR, SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDGIS-2470 , Dated: August 10,2015
Provided: Construction shall be completed within six months of the date of this permit. All local condirions must be met.
CONDITIONS:
1. SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,650 GAL PUMP CHAMBER,
DBOX, 20 ADS ARC36LP UNITS W/OUT STONE: 25'X 11.3'X 3.3"
2. MFC VARIANCES APPROVALS: a. SETBACKS b. GROUNDWATER c. WETLAND SETBACKS
3. BOH TO INSPECT SOIL REMOVAL
4. ELECTRICAL PERMIT REQUIRED
Bruce G. u hy, MPH, R.S., HO/Amy L. von Hone, R.S., CHO
Health Director!Assistant 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 Fee
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: 11 CAPE ISLE DR, SOUTH YARMOUTH,MA 02664
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 applicarion No.: BOHDC-15-247Q dated]0/09/2015.
Installer:CHASE&MERCHANT INC.
Address:P.O.BOX 5 DENNISPORT,MA 02639 Inspector:AMY VON HONE,R.S.
Designer: OCEANSIDE SEPTIC
��� �
i � /
C/
Bruce G. Murph ,M , R.S., CHO/Amy L.von Hone, R.S.,CHO
Health Diredor/Assistant Health Diredor
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
BO H_Disposal_Construdion_CofC.rpt