HomeMy WebLinkAboutApp-Permit-ComplianceE,
No. DOW 17C-1- 5? q0 FEE 4W-00
ta-ooaqoCOMMONWFALTI�P� Ck*-3861
ASSACHUSETTS
r4•..I,TH HEALTH DEP-1.
Board of Health, 1148 R011TE 28 AM.
APPLICATION FOP, DISPOSAI MSI®N PERMIT
Application for a Permit to Construct(ft/Repair( ) Upgrade( ) Abandon() - R Complete System ❑ Individual Components
Location T ,,/d�'d „� j✓ /
Owner's Name
Map/Parcel#k -3 Y IX<d2,00
Address 4 � '
Lot#
Telephone#
Installer's Name 1 elelB, b/ A-
Designer's Name.9!!�),,&,.,� ��j�,/'��1'��G ✓�
Address e ,� T .4 411 3 -119�k 1.117714
Address
Telephone# 7;;�� r -l" ,d' <77S
Telephone#
Type of Building" Lot Size _ sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)® gpd Calculated design flow
Plan: Date Jl - ---10 -'l S" Number of sheets %
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided �f05�7 gpd
Revision Date
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 agre o of to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. 80N DC —15 — 5710 E
COMMONWEALTH Of MASSACHUSETTS D� �S Ck*380 I
Board of Health, �!y/�/ , AM
CERTIFICATE Of COMPLIANCE �� �-, 7�,�r! �✓�{� J �� �'�L/
Description of Work: ❑ Individual Component(s) 4tomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: G -ez, o e- �/e� .J� �`G�l C J' C
has been installedi}n accoofda"ice withthe''roWsions of NO CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. 17/ , dated /S . Approved Design Flower (gpd)
Installer �,� 1 eeo4- /—
Designet:4�Q :%%%��Or X-' Inspector: L�/,�,i[.L-f Date:
The issuance of this permit shall not be construed as a guaran ee that the system will function as designed.
No. 601+DC-IC5--57% 0 -T1 (* L(;-; &OemF ,eY I)C Svc 1
/ �--2 71 COMMONWEALTH Of MASSACHUSETTS
Board of Health, /�/� o&V7**41' , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE `l' J ® C)
Ck-* 3 8(01
Permission is hereby granted to,;jCoVnstruct(,4r Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. /S� .:,)-// , dated
Provided: Construction shall be completed within t,of the date of this permit. All local conditi ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestnn, M Date �� �� �� Board of Health
' No.:BOHDC-15-5790
Commonwealth of Massachusetts F�
, $o.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
Location: 40 NOBBY LN,WEST YARMOUTH, MA 02673 Owner:
SILVA MARGARET M
Map/Parcel#: 039.230 PO BOX 550197
WALTHAM,MA 02455-0192
Phone:
Septic System Installer Designer
JIM LEBOEUF SEPTIC DAVID B. MASON,R.S.
55 BODICK ROAD HYANNIS, MA 02601 4 GLACIER PATH
Phone: EAST SANDWICH,MA 02537
5087750707 508-367-1617
Type of Building:Dwelling Lot Size:9,148.00 Sq.Ft.
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Pian Date: 11/10/2015 Number of Sheets: 1 Cafeteria:
' TitIe:SITE AND SEWAGE PLAN 40 NOBBY LANE Revision Date:
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:349 gpd
: Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: 11/04/2015
DAVID B.MASON,R.S.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,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 Comnliance has been issued bv the Board of Health.
Signed Date
Inspections
� Commonwealth of Massachusetts
� Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is herby granted to;
JIM LEBOEUF SEPTIC SERVICE, 55 BODICK ROAD, HYANNIS, MA 02601
To perform: Upgrade an individual sewage disposal system.
Owner: SILVA MARGARET M
PO BOX 550197
WALTHAM,MA 02455-0192
Location:40 NOBBY LN, WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-5790,Dated:November 20,2015
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-PROPOSED 1500 GAL SEPTIC TANK, DBOX,2-500 GAL PRECAST
CHAMBERS W/4'STONE:25'X 12.83'X 2'
�-�(
Bruce G.M hy,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.
i �,,.��
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
�' CERTIFICATE OF COMPLIANCE $55.00
;
Description of Wark:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:JIM LEBOEUF SEPTIC SERVICE
at:40 NOBBY LN,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-15-5790,dated 12/Ol/2015.
Installer:JIM LEBOEUF SEPTIC SERVICE
Address:55 BODICK ROAD HYANNIS,MA 02601 Inspector:AMY VON HONE,R.S.
Designer:DAVID B.MASON,R.S.
Conditions
1.SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,2-500 GAL
PRECAST CHAMBERS W/4'STONE: 25'X 12.83'X 2'
�vC�
Bruce . urphy, 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.
BO H_Disposal_Construction_CofC.rpt
I
�
i