HomeMy WebLinkAboutApp-Permit-ComplianceNo. l�'t% % }lr ��' 7 a0 / � FEE
CO?MONWEALTII OF MASSACHUSETTS
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�7k-PAI-LICATI'ON FOR DISPOSAL S STEM[ ��N TRUCTI®N PERMIIT
pplication for a Permit to Construct( ) Repair( ) Upgr O AbandonO Complete System ❑Individual Components
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Location
Owner's Name l
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Map/Parcel# ��' n
Address S w C emnA--h
Lot#
Telephone# g 6 d -- -7 q S
Installer's Name Cl�
Designer's Name D r�
Address` q
Address
Telephone# `� - /
Telephone#
Type of Building I
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size
sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. re uired) gpd Calculated design flow Design flow provided gPd
Plan: Date i Q (1+ l 5 Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
t 500 aP.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Rib
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Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree t to place to operation until a Certificate of C mplian� has been issued by the Board of Health.
Signed Date
Inspections x-
No. &V17W'ls--7� FEE
7� COM[MON�I.T14 Of MASSACHUSETTS O -, l��D�rw,
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Board o Health,
CERTIFI Of COMPLIANCE
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Descri tion of Work: ❑ Individual Component(s) onent(s) C� o to System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ()eAla`ndoned ( )
by: R 113 -)(Ir rlvrc1 iva
at
has been installe in c r2 ait with �;i p�o sions of 31 CMR 15.00 (Title 5) and th�pproved design plans/as-built plans relating to
applicato.`_ S= / , dated / 2 Approved Design Flow �(gpd)
Installer i:. i)6PigI 1--'1 l (it /1V
Date: /2-- 16 -/.5:
The issuance of this permit shall not be construed as a guaran�6 thaf the system will function as designed.
FEE .�
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, ) YA ej\AQUT-4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade�andon ( ) an individual sewage disposal system
at 7) ) i o i) X a Lao as described in the application for
Disposal System Construction Permit No. dated
p L C-�— 7 p
Provided: Construction shall be com le ed within sof th�date of this erm t. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslawn, MA Date // :��Board of Health/
r jou v .6 /,p
" No.: BOHDGIS-5679
Commonwealth of Massachusetts Fee
ass.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
Location: 8 SIOUX RD,WEST YARMOUTH, MA 02673 Owner:
BERTHIAUME WILLIAM A
Map/PerCel#: 024.113 C/O MICHELE WHEELOCK
34 H[JDSON ST
NORTHBOROUGH,MA O1532
Phone:
Septic System Installer Designer
B&B EXCAVATION MORAN ENGINEERING ASSOC.,LLC
14 TEABERRY LANE FORESTDALE, P.O.BOX 183
MA 02644 SOUTH HARWICH,MA 02661
Phone: 508-432-2878
5084770653
Type of Building:Dwelling Lot Size: 13,(168.00 Sq.Ft.
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fiatures:
Plan Date: 10/16/2015 Number of Sheets:2 Cafeteria:
Title:SITE AND SEWAGE PLAN 8 SIOUX ROAD Revisioo Date:
• Design Flow(min.required):220 gpd Calculated design flow:330 gpd Design ilow provided:338 gpd
Descripfion of Soi1s:SEE PLAN
• Soii Evaluator Form No.: Name ot Soil Evaluator. Date oCEvaluation:08/13/2015
RICK NDD,R.S.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX, 12
CULTEC CANTACTOR 100HD UNTIS W/OUT STONE:30.5'X 11'X 0.5'
The undersigned agrees to insfall the above deseribetl IntliviCual Sewage Dlsposal System in aceortlanee with the provislons of
TITLE 5 antl fuRher aarees no!to olace in ooeratlon untll a Cerfiflcate of Comolianee has heen iasued hv the Board of Meskh.
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT 855.00
Permission is herby granted to;
B&B EXCAVATION, 14 TEABERRY LANE, FORESTDALE,MA 02644
To perform:Upgrade an individual sewage disposal system.
Owner: BERTHIAUME WILLIAM A
GO MICHELE WIIEELOCK
34 H[JDSON ST
NORTHBOROUGH,MA 01532
Location: 8 SIOUX RD, WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-5679,Dated:November 12,2015
Provided: Construction shall be completed within six months of the date of this permit. All loca]wnditions must be met.
CONDITIONS:
1. SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK, DBOX, 12 CULTEC CONTACTOR
100HD UNTIS W/OUT STONE: 30.5'X 11'X 0.5'
2. MFC VARIANCE APPROVAL:a. REDUCED GROUNDWATER ADJUSTMENT
3. PLUMBING PERMIT REEQUIRED
4. BOH&ENGINEER TO INSPECT SOIL REMOVAL AND FINAL INSTALLATION
Bruce G. Murphy, P. , R.S., CHO/Amy L. von Hone, R.S., CHO
He Director/Assistant Health Director �
The issuance of this permit shall nat be construed as a guarante that the system will function as designed.
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
CERTIFICATE OF COMPLIANCE $55.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:B&B EXCAVATION
at: 8 SIOUX 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-15-5679,dated 12/17/2015.
Installer:B&B EXCAVATION
Address:l4 TEABERRY LANE FORESTDALE,MA Inspector:AMY VON HONE,R.S.
02644
Designer:MORAN ENGINEERING ASSOC.,LLC
Conditions
1.SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,12 CULTEC
CONTACTOR 100HD UNTIS W/OUT STONE:30.5'X 11'X 0.5'
2.MFC VARIANCE APPROVAL:a.REDUCED GROUNDWATER ADJUSTMENT
3.PLUMBING PERMIT REEQUIRED 0/'G %a ���%-�� �L_�{�i� -�U � ��5� 7
4.BOH&ENGINEER TO INSPECT SOIL REMOVAL AND FINA INSTALL T N
Bruce G. Mu y, MPH, 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.
BOH_Disposal_Construction_CofC.rpt '
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