HomeMy WebLinkAboutApp-Permit-ComplianceNo. 4433
COMMONWFALT14 Of MASSACHUSETTS
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Board of Health, 7X1��(lTfl
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad ( bandon( ) - 9 Complete System ❑ Individual Components
Location 1AI ' RdOwner's
Name
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Map/Parcel#i i
Address
Lot#
Telephone#
Installer's Name 114, ke S e
Designer's Name
Address 9 9 CGRt"l✓�
Address
Telephone# v 6 Z
Telephone# % p V
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) % gpd Calculated design flow Design flow provided{�X gpd
Plan: Date /s- Number of sheets % Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No. Name of Soil Evaluator. Ro'.4 /46e��[,/ Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS GG t" a /Q 6" e r r c- d /.,
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
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Signed 2E56;16 A %
Date � � �!
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No. �C-1J-- `�3 j \ FEE 5
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COMMONWEALTH OF MASACIIU ETTe
Board of Health, Y6!&M0Q1)4 , MA. VD
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ®''Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded abandoned ( )
by:
at
has been installed irri Tc'co"r&nce ivitli the `provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / i -2/ Z, dated - .Z Z i 7 Approved Design Flow �i ' (gpd)
Installer AW P
Designer: Inspector: i' Date:
The issuance of this permit shall not be construed as a guars tee that the system will function as designed.
No. 13 6 S rc-rtp FEE
�oNpc-d5-4� 33
COMMONWEALTH Of MASSACHUSETTS cn---F z_(0�
Board of Health, Y69=MD,'MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade.(/�lAbandon ( ) an individual sewage disposasystem
at f� '612 4 lc'aCd , as described in the application for
Disposal System Construction Permit No. , dated
�Provided: Construction shall be compl�Eed within t rPP �� o the date oaf this permi All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 9=1 -7%� Bo* nd of ealth
No.:BOHDGIS-4433
� Fee
Commonwealth of Massachusetts
$55.00
Board of Health, Yarmouth, MA I
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
Location:46 WILSON RD,WEST YARMOUTH,MA 02673 Owner:
DAUPHINAIS AGNES M
Map/Parcel#:058.116 KEEFE LOIS M '
200 DEAN ST
NORWOOD,MA 02062-4783
Phone:
Septic System Installer Designer
BOSETTI SEPTIC RONALD J.CADILLAC.PLS.RS,PC
199 CHURCH STREET EAST P.O.BOX 258 '
HARWICH, MA 02645 WEST YARMOUTH,MA 02673 '
Phone: 508-775-9'700 '
Type of Building:Dwelling Lot Size:9,148.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder.
Ot6er Type of Building: No.of persons: Showers:
Other Fistures: '
Plan Date:09/02/2015 Number of 56eets: 1
Cafeteria:
Title:SITE PLAN 46 WILSON ROAD Revision Date:
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:345 gpd
Description of Soi1s:SEE PLAN �
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:08/06/2015
RONALD J.CADILLAC,RS
i
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,12
�
ADS ARC 35HC iJNITS W/OUT STONE:TWO TRENCHES IN 30'X 2.89;X 0.89'CONFIGLIRATION
� 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 nlace in ooeration until a Certi£cate 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 Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is herby granted to;
BOSETTI SEPTIC SYSTEMS, 199 CHURCH STREET, EAST HARWICH, MA 02645
To perform:Upgrade an individual sewage disposal system.
Owner: DAUPHINAIS AGNES M
KEEFE LOIS M
200 DEAN ST
NORWOOD,MA 02062-4783
Location:46 WILSON RD,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-4433,Dated: September 22,2015
Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met. i
CONDITIONS:
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1. SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK, DBOX, 12 ADS ARC 35HC UNITS II
W/OUT STONE:TWO TRENCHES IN 30'X 2.89;X 0.89'CONFIGURATION
2. MFC VARIANCE APPROVAL:a.SETBACKS
CS� . �
Bruce G. Murp , H, R.S., CHO/Amy L.von Hone, R.S.,CHO i
alth 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 Fee
CERTIFICATE OF COMPLIANCE 555.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:BOSETTI SEPTIC SYSTEMS
at:46 WILSON 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-15-4433,dated 10/06/2015.
Installer:BOSETTI SEPTIC SYSTEMS
Address:199 CHURCH STREET EAST HARWICH,MA Inspector:AMY VON HONE,R.S.
� 02645
Designer:RONALD J.CADILLAC,PLS,RS,PC
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Bruce G. Murphy, H, .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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