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HomeMy WebLinkAboutApp-Permit-ComplianceNor. f,6'+j dJC�t �� V jEjl-e ' �14 k/ A�04a--� r 6pq` � 7 FEE 4. 55, 00 COMMONWEALTH OF MASSACHUSETTS 90053 Board of Health, -1 R -a mO na , MA. APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location a P1 n i J✓ 57. C4 Owner's Name p Map/Parcel# % Z Address �. /�4 r ,,tJ 5 j Lot# Telephone# ') /7 - 33C r % )d-'), Installer's Name VC t-,�J Wpm Designer's Name Address L16 f© %— e) fr_ Address Telephone# �� �(o(�: g9fl- C,4 �� a(S 3�16f Telephone# �It— Type of Building Dwelling - No. of Bedrooms Other - Type of Building 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 Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS fzq C� J? - R7Y .13a- A,e- 16LO 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 no o pla e m in operation until a Certificate of Compliance. has been issued by the Board of Health. Signed A, 17 Date /n -30 -15 - Inspections No. tJ�'w � �~ FEE �i - , COMMONWEALTH OF MASSACHUSETTS 00 Board of Health, p"62-ma3 m , MA. rw -or ! 6sy p /1 407 $''Jell Upgraded ( ), Abandoned ( ) /11 CERTIFICATE Of COMPLIANCE Description of Work: PJ Individual Component(s) 0 Complete System r; The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),� paired] by: Fg'ep se'nISCJ- W i KD 1R -(Vic. V--ha9lfL taiMGWIP at .�?FoZ M91�57'.- -- L has been installed in accorydaance ith f e prop Bions o 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. �r -67- dated /�� Approved Design Flow (gpd) Installer r1 A Designer: �` Inspector: J�' (/�� C f Date: p :r,_ _ �a -.,i ��.r :�,, v:, ;.,^"' The issuance of this permit shall not be construed as ay ran a that the yst�e�m will function as designed./l � No. d iTV W (K)V �V eV =�Y(�> l FEE 5Z5, bO COMMONWEALTH OF MASSACHUSETTS Board of Health, qPW 1MQ OTVi , MA. C,k-* 8 9013 DISPOSAL SYSTEM CONSTRUCTION PERMIT Permissionishereby granted to; Construct(�epair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at ��WG�` %y%%�t �% ``4` as described in the application for Disposal System Construction Permit No. dated 54 Yc,— Provided: Construction shall be completed within t f the date of this permi All �local �co�nditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Z �� Board of Health No.:BOHDGIS-5485 Commonwealth of Massachusetts F� sss.00 Board of Health, Yarmouth, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to:Repair-minor-Individual Component(s) Location: 382 ROUTE 6A,YARMOUTH PORT, MA 02675 Owner: DOLAN MARGARET A TR Map/Parcel#: 123.40 C/O AMY DOLAN 217 WALLACE AVENUE BUFFALO,NY 14216 Phone: Septic System Installer Designer WIND RIVER 577 MAIN STREET, SUITE 110 HUDSON,MA 01�49 Phone: 5086686994 Type of Building:Dwelling Lot Size:28,314.00 Sq.Ft. Dwelling-No.of Bedrooms:3 Garbage Grinder: Other Type of Building: No.of persons: Showers: Other Fiatures: Plao Dah: Number of Sheets: Cafeteria: Title: Revision Date: Desigo Flow(min.required):330 gpd Calculated design Flow:330 gpd Design Flow provided:330 gpd Description of Soils: Soil Evalustor Form No.: Name of Soil Evaluator: Date of Evaluation: DESCRIPTTON OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX PER T[TLE 5 INSPECT[ON REPORT DATED 08/31/15 TO EX[ST[NG 1000 GAL SEPTIC TANK,6'LEACH PIT W/2'STONE The undersigned agrees W Install fhe above tleaeribetl Intlivitlual Sewage Disposal System in accordance with the provblons of TITIE 5 antl furfher aarees not to olace In ooeretion untll a Cerfifieafe of Comolianee has heen iesued bv the 8oard of Fleakh. Signed Date Inspectio�s Commonwealth of Massachusetts Board of Health, Yarmouth, MA F� DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00 Permission is herby granted to; WIND RIVER ENVIRONMENTAL, 577 MAIN STREET, SUITE 110, HUDSON, MA 01749 To perform:Repair-minor an individual sewage disposal system. Owner: DOLAN MARGARET A TR C/O AMY DOLAN 217 WALLACE AVENUE BUFFALQ NY 14216 Location:382 ROUTE 6A,YARMOUTH PORT,MA 02675 Disposal System Construction Permit No.: BOHDC-15-5485,Dated:November 03,2015 Provided:Cons[ruction shall be completed within six months of the date of this permit. All local conditions mus[be met. CONDITIONS: 1. SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX PER TITLE 5 INSPECTION REPORT DATED OS/31/15 TO EXISTING 1000 GAL SEPTIC TANK,6'LEACH PIT W/2'STON �.�sf' Bruce G. urphy, MPH, R.S., CHO/Amy L. von Hone, R.S.,CHO Health Director/Assistant HeaNh 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 $55.00 Description of Work: Individual Component(s) The undersigned hereby certify that the Sewage Disposal System; Repair -minor by: WIND RIVER ENVIRONMENTAL at: 382 ROUTE 6A, YARMOUTH PORT, MA 02675 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-15-5485, dated 11/10/2015. Installer: WIND RIVER ENVIRONMENTAL Address:577 MAIN STREET, SUITE 110 HUDSON, Inspector: AMY VON HONE, R.S. MA 01749 Designer: Conditions 1. SEPTIC DISPOSAL - MINOR REPAIR - REPLACE DBOX PER TITLE 5 INSPECTION REPORT DATED 08/31/15 TO EXISTING 1000 GAL SEPTIC TANK, W -LEACH T STONE v(P Bruce G. Murphy, R.S., CHO / 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. L BO H_Disposal_Construction_CofC. rpt