HomeMy WebLinkAboutApp-Permit-Compliance-tv,e-(Ar . 16o -Y037
No. ('v�RW- IL --N) THE COMMONWEALTH OF MASSACHUSETTS FEE
16--11 �, /BOARD F HEALTH" `� 7'-�
L / v OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair Z—)
Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components
Location
52
Ma
310
Installer's N me
n l n�yYin�P 4am AZ a
v� Address
scvy
Telephone #
Type of Building: S -ED,
Dwelling — No. of Bedrooms 3)
Other — Type of Building No. of persons
Other fixtures
Design Flow (mi . re uired) 3b gpd Calculated
Plan: Date 1/7*
N mber of sheets
Title 51'7i Z6wk-/ i
Description of Soil(s) E' G S t e i)VE
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTIO OF EPAIRS OR ALTERATIONS
_qVV ��ry O, S G Z/ / JyV7 /e _ z
�� Address
11 -1 .A Telephone #
Ad r ss /
Telephone #
Lot Size 09 • Z T- -Sq--�
Garbage Grinder N®
Showers ( ), Cafeteria ( )
flow J �8 gpd Design flow provided "—Ygpd
Date of Evalua
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further
`agre s not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ,/ ��-``��"' Date
Inspections
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. e,o+1)r_ - (o-7"" THE COMMONWEALTH OF MASSACHUSETTS FEE5t 5-- 0
16-11 l BOARD OF HEALTH Ck#39714
C RTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded ( ), Abandoned ( )
at / W / t t / ! 0 A- V f (7V h- / I -K '
has been installed in accordance with the
plans relating to application No.
Installer 5
W ,
provisi ns of 310 CMR 15.0/00 (Title 5) and the approved design plans/as-built
dated / T !o°(��. Approved Design FlowF�y_(gpd)
r
Designer:7). )-.�.�i� /� Inspector
-
to L
/..,. �..�.. '""rr
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. Y VNDC_�(o � I�THE COMMONWEALTH OF MASSACHUSETTS FEE 5,5, 00
� 't- 'ri BOARD OF HEALTH � -7
G�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereb granted to Construct ) Repair ( Upgrade ( )Abandon ( ) an individual sewage
disposal system at r,ll'� hca?e -�rar1 ,r/1 jl as described
in the application for Disposal System Construction Permit No, - / dated /-- / -/4'
Provided: Construction shall be completed within t-kfee-yeftrs of the ate of this p�mit A.pjml conditions must be met.
Date / / C, / (e B and of Health C`1 % C/
FORM 2 - DSCP DEP APPROVED FORM 5/96 X
FORM 1255 (REV 5/96) H HOBBS& WARREN TM PUBLISHERS - BOSTON
No.:BOHDGI6-7911
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: 16 MIRROR BROOK RD,WEST YARMOUTH, MA 02673 Owner:
PIRROTTA DAIVIEL
Map/Parcel#: 058.330 16 MIRROR BROOK RD
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
ELLIS BROTHERS FLAHERTY ENVIRONMENTAL SERVICES
PO BOX 59 YARMOUTHPORT, MA P.O.BOX 81
02675 YARMOUTHPORT,MA 02675
Phone: 508-362-1657
5083626237
Type of Building:Dwelling Lot Size: 10,890.00 Sq.Ft.
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
, Plan Date: 11/OS/2015 Number of Sheets:2 Cafeteria•
Tit1eSITE AND SEWAGE PLAN 16 MIRROR BROOK ROAD Revision Date:
• Design Flow(min.required):220 gpd Calcuiated design flow:220 gpd Design flow provided:348 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:08/12/2008
EDWARD STONE,PLS
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXSTING 1500 GAL SEPTIC TANK,PROPOSED
DBOX,2-50 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 wkh 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
,
' � Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
Permission is herby granted to;
ELLIS BROTHERS CONSTRUCTION, PO BOX 59,YARMOUTHPORT, MA 02675
To perform:Upgrade an individual sewage disposal system.
Owner: PIRROTTA DANIEL
16 MIRROR BROOK RD
WEST YARMOUTH,MA 02673
Location: 16 MIRROR BROOK RD,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-16-7911 ,Dated:January 15,2016
Provided:Construction shall be completed within six months of the date of this permit. Aii local conditions must be met.
CONDITIONS:
SEPTIC DISPOSAL-REPAIR-EXSTING 1500 GAL SEPTIC TANK, PROPOSED DBOX,2-50 GAL PRECAST
CHAMBERS W/4'STONE:25'X 12.83'X 2'
���-��''���
,
Bruce G.Murphy,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.
-s
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
� CERTIFICATE OF COMPLIANCE $55.00
Description of Work:Individual Component(s)
� The undersigned hereby certify that the Sewage Disposal System; Upgraded
I
� by:ELLIS BROTHERS CONSTRUCTION
i
; at: 16 MIRROR BROOK RD,WEST YARMOUTH,MA 02673
� Has been installed in accardance with the provisions of 310 CMR 15.00(Title 5)and the approved
I
design plans or as-built plans relating to application No.: BOHDC-16-7911,dated Ol/22/2016.
Installer:ELLIS BROTHERS CONSTRUCTION
Address:PO BOX 59 YARMOUTHPORT,MA 02675 Inspector:AMY VON HONE,R.S.
Designer:FLAHERTY ENVIRONMENTAL SERVICES
Conditions
SEPTIC DISPOSAL-REPAIR-EXSTING 1500 GAL SEPTIC TANK,PROPOSED DBOX,2-50
GAL PRECAST CHAMBERS W/4' STONE: 25'X 12.83'X 2'
C/��'G�E���
Bruce G. Murph 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