HomeMy WebLinkAboutApp-Permit-ComplianceNo. bO�M-
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COMMONWEALTH .I.TH ®F MASSACHUSETTS
t Board of Health, YAWO (7TH , MA. 025 LZTI?-- ((o 00 2—q 2—q
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade�bandon() - 0 Complete System M-15�dividual Components
Location
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Owner's Name ( S
Map/Parcel#4t
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Address
Lot#
Telephone#
Installer's Name
P-)+�,Xwwtton
Designer's Name 't)Q,4toa S U n
Address 14-Tw-be-rcv
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Address p G Com. 17n V ( f D n M -P -c CL)
Telephone#
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Telephone# 60q 33 q
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size4 Litsq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) .3D gpd Calculated design flow ::�Q Design flow provided gpd
Plan: Date kI L�! Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigne agr s to install the above des ' ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o no to ace th sys in o r 'on until a Certificate ofiiC mpl'ance has been issued by the Board of Health.
Signed n Date 1 7
Inspections
No. fN 9ri `j- �(v FEE SCJ G U
COMMONWEALTH Of MASSACHUSETTS j
Board of Health, YA (ZN1y�-i , MA.
T fCOMPLIANCE
CERTIFICATE ® /
Description of Work: -0 ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( )
has been installeYin accordant cie with the provisions of 3_10 CMR 15.00 (Title 5) and the Qproved design plans/as-built plans relating to
application No / -4 C4 dated 15 Approved Design Flow �� (gpd)
Installer t i x 1 i i i G R f i 9 6, L �c� 9, r<< lj" ✓' : O�-o';, y,.
, t Date: `>
Designer: ! C U! F, l d '.:-Inspector: %i r = -'
The issuance of this permit shall not be construed as a guararifee that the system will function as designed.
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COMMONWEALTH Of MASSACHUSETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade_( -j Abandon( ) an individual sewage disposal system
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at t ( k� - i -� - as described in the application for
Disposal System Construction Permit No. /t7 , dated
Provided: Construction shall be completed within three_ye-axs-of.the date of this permit; All local conditions must be met.
�% / oard of Health,-
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date % _
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No.:BOHDGIS-5856 '
Commonwealth of Massachusetts Fee ,
' $55.00 ,
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to: Upgrade-Individual Component(s)
Location: 64 CAPT NICKERSON RD, SOUTH YARMOUTH, MA Owner:
02� MATSIS JEFFREY W
Map/Parcel#: 088.261 MATSIS ALETHA
64 CAPT 1�TICKERSON RD
SOUTH YARMOUTH,MA 02664
Phone:
Septic System Installer Designer
B&B EXCAVATION DAVID B. MASON,R.S.
14 TEABERRY LANE FORESTDALE, 4 GLACIER PATH
MA 02644 EAST SANDWICH,MA 02537
Phone: 508-833-2177
5084770653
Type of Building:Dwelling Lot Size: 13,504.00 Sq.Ft.
Dwelling-No.of Bedrooms:3 Garbage Grinder•
Other Type of Building: No.of persons: Showers:
Other Fixtures: '
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Plan Date: 11/12/2015 Number of S6eets• 1 Cafeteria:
. Tit1e:SITE AND SEWAGE PLAN 64 CAPTAIN NICKERSON ROAD Revision Date: 11/18/2015 �
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Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:348 gpd �
� Description of Soi1s:SEE PLAN (
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: 11/04/2015 '
DAVID B.MASON,RS.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,PROPOSED i
DBOX,2-500 GAL PRECAST CHAMBERS W/4'STONE:25'X 12.83'X 2' �
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 ooeration until a Certificate of Comoliance has been issued bv the Board of Health.
Signed Date
Inspections �
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Commonwealth of Massachusetts
� Board of Health, Yarmouth, MA F� '�!
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55•°° ;
Permission is herby granted to; "
B&B EXCAVATION, 14 TEABERRY LANE, FORESTDALE,MA 02644
To perform:Upgrade an individual sewage disposal system.
Owner: MATSIS JEFFREY W
MATSIS ALETHA
64 CAPT NICKERSON RD
SOUTH YARMOUTH,MA 02664
Location:64 CAPT NICKERSON RD, SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDC-15-5856,Dated:November 19,2015
Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met.
CONDITIONS:
1.SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK, PROPOSED DBOX,2-500 GAL
PRECAST CHAMBERS W/4'STONE:25'X 12.83'X 2'
2. MFC VARIANCE APPROVED:a. SETBACK TO FOUNDATION
3.ZONE II MAXIMUM 3 BEDROOMS
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Bruce G. Murp ,M H, R.S., CHO/Amy L.von Hone, R.S., CHO j
H Ith Director/Assistant Health Director �
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
CERTIFICATE OF COMPLIANCE $55.00
Description of Work: Individual Component(s) �'
The undersigned hereby certify that the Sewage Disposal System; Upgraded '
by:B&B EXCAVATION
at:64 CAPT NICKERSON RD, 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 application No.: BOHDC-15-5856,dated 11/23/2015.
Installer:B&B EXCAVATION
Address:l4 TEABERRY LANE FORESTDALE,MA Inspector:AMY VON HONE,R.S.
02644
Designer: DAVID B. MASON,R.S.
Conditions
1. SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,PROPOSED DBOX,2-
500 GAL PRECAST CHAMBERS W/4' STONE:25'X 12.83'X 2'
2.MFC VARIANCE APPROVED: a. SETBACK TO FOUNDATION
3.ZONE II MAXIMUM 3 BEDROOMS / ,
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Bruce G. Murp ,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.
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BOH_Disposal_Construction_CofC.rpt I
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