Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo. j� DG� ito�7�82 �) (� l �- l 6-dL��d3 j FEE ,6 COMMONWEALTH LTH ®f MASSACHUSETTS Ajw41`oW YARM"UTH HEALTH DEPT. Board of Health, 1146 ROUTS 26 , MA• APPLICATION FOR DISP®SAf 8W ION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System 9Individual Components Location /!%� Owner's Name Map/Parcel# Address P Lot# Telephone# %%Si` -7- Installer's Name �/� `��'©� �jr Designer's Name,Qo -'ce Address 4:< Address Telephone# Telephone#�e� Type of Building 410 ' "f' 'P` Dwelling - No. of Bedrooms Other - Type of Building Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 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 nF.SCRIPTiON 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 agre o t to place ttW system in operation until a Certificate of Co plian has been issued by the Board of Health. Signed 4 Date Inspections No. 6014-DC'140-7$0z ,1 G/ % FEE 55. do COMMONWEALTH OF MASSACHUSETTS'/ Board of Health, ����8" 71Y , MA. /V CERTIFICATE Of COMPLIANCE 14 �� Description of Work: L� Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (<UUpgraded ( ), Abandoned ( ) by: at C? 11WA ,A`..., J' .®Ge�i'�' �s,��✓ii®t/T'/y����'- // - 7 has been installed in acco' rclance with the provisions of 3;0 CMR 15.00 (Title 5) and thea prr�oved design plans/as-built plans relating to application No. % , dated /-- /2_ ^mak . Approved Design Flow —3:gpd) Installer `el$674 'E U/r Designer: -61P ti -*" Gid &'C'd Inspector: The issuance of this permit shall not be construed as a guara � ft,,) i"(-! r L�W� Date: / — /3 —16 that the system will function as designed. COMIM ONWEALT14 Of M ASSAC14USETTS Board of Health,MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE J ®Q Permission is hereby granted to; Construct( ) Repair( ) Upgrade( andon( A<an individual sewage disposal system at J .� ® T as described in the application for Disposal System Construction Permit No. 1,6 —/d , dated Provided: Construction shall be completed vathin t..r-ee-?N r- of the date of this perm All local con 'tions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date �� lL �b Board o Health / 1 ; � � � I No.:BOHDC-16-7882 i Commonwealth of Massachusetts Fee $55.00 Board of Health, Yarmouth, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to:Repair-minor-Individual Component(s) Location: 8 MATTIS DR,YARMOUTH, MA 02675 Owner: DUBOIS JOSEPH H Map/Parcel#• 141.13 C/O BRiJNO REGINA CAMERON . 31 GREENDALE AVE MARLBOROUGH,MA 01752 Phone: Septic System Installer Designer JIM LEBOEUF SEPTIC 63 CIT AVENUE HYANNIS, MA 02601 Phone: 5087750707 Type of Building:Dwelling Lot Size: 11,761.00 Sq.Ft. Dwelling-No.of Bedrooms:3 Garbage Grinder: Other Type of Building: No.of persons: Showers: Other Fixtures: Plan Date: Number of Sheets: Cafeteria• Title: Revision Date: Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:489 gpd Description of Soils: Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-RELOCATE PROPOSED 1500 GAL SEPTIC TANK TO EXISTING DBOX AND 4'LEACH PIT W/3'STONE FOR PROPOSED ADDITION The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further aarees not to olace in ooeretion until a Certificate of Comnliance has been issued bv the Board of Heakh. Signed Date Inspections � Commonwealth of Massachusetts � Board of Health, Yarmouth, MA Fee DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00 Permission is herby granted to; JIM LEBOEUF SEPTIC SERVICE,63 CIT AVENUE, HYANNIS, MA 02601 To perform:Repair-minor an individual sewage disposal system. Owner: DUBOIS JOSEPH H C/O BRUNO REGINA CAMERON 31 GREENDALE AVE MARLBOROUGH,MA 01752 Location: 84 ELLIS CIR,YARMOUTH,MA 02675 Disposal System Construction Permit No.: BOHDC-16-7882,Dated:January 12,2016 Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met. CONDITIONS: SEPTIC DISPOSAL-MINOR REPAIR-RELOCATE PROPOSED 1500 GAL SEPTIC TANK TO EXISTING DBOX � AND 4'LEACH PIT W/3'STONE FOR PROPOSED ADDITION � V � Bruce G. M phy,MPH, R.S., CHO/Amy L.von one, 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. � � i �