HomeMy WebLinkAboutApp-Permit-ComplianceNo. I -r, , � ` 16 � o a,3, FEE
COMMONWEALTH OF M ASSAC14USETTS -4
Board of Health,YA124'Vli� L)T , MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon() - ❑ Complete SystemXIndividual Components
Location icl N.
Q Owner's Name
'
Map/Parcel# a
AddressQM
Lot# capTelephone#
Installer's Name
Designer's Name
Address t
Address' ?Z.
Telephone# p e —
Telephone#
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Type of Building �ZaS l�Q�, Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder cep i
Other - Type of Building I A No. of persons�or _ Showers (&)!Cafeteria (lY
Other Fixtures Laos c-� k� *1 Sink . __ _ sac,,ekyc,t
Design Flow (min. required)3 8v gpd Calculated design flow l7 Design flow provided 'Yglf-soigpd
Plan: Date _{ � ) 1 Number of sheets .Z Revision Date
Titley r-� ?�C-
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 5) zs&w,
The undersigne gree 1 above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees not to ace e t in in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
COMMONWEALTH OF MASSACITUS
Board of Health, YYAj?=64QU 14
CERTIFICATE Of COMPLIANCE �'� � �$ 4,eel4 �
Description of Work: individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired X, Upgraded ( ), Abandoned ( )
by:�,�':�' P KAP 5 t-t#rN aN1�—"�a rk�
at pg L►5
has been installe to ac ordanc with tt'i pro zsions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ��i �-a dated -"-� --1` Approved Design Flow 440 (gpd)
Installer
Designer: i ,f~iZc-\V-s S+\R-'! Inspector: � � "` "� ' Date:
The issuance of this permit shall not be construed as a guaran a that/die system will function as designed.
No. 6��" I �! C ht'� FEE CJ
COMMONWEALTH Of MASSACHUSETTS CJ"-� � �
Board of Health, YO24'>rf.Q UTA , MA.
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DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair
Upgrade( ) Abandon( ) an individual sewage disposal system
at 1� Nr� r�� .��� ��) as described in the application for
Disposal System Construction Permit No. /If;-- C.1 , datedZr-
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Provided: Construction shall be completed within tlrr�ycaff of the date of this pe�ni�. All local cond'tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health /
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� � No.:BOHDGIS-5541
Commonwealth of Massachusetts Fee
I� $55.00
' Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Application for a Permit to:Upgrade-Individual Component(s)
Location: 19 NORTH SANDYSIDE LN,YARMOUTH PORT, MA Owner:
02675 ALBERTI RALPH C TRS
Map/Parcel#: 122.1 ALBERTI FLORENCE M
19 N SANDYSIDE LN
YARMOUTH PORT,MA 02675-1750
Phone:
Septic System Installer Designer
SHAY CARMEN E. SHAY ENVIRONMENTAL SER�
P.O. BOX 1576 MASHPEE, MA 02649 P.O.BOX 1576
Phone: MASHPEE,MA 02649
5082947498 508-294-7498
Type of Building:Dwelling Lot Size:40,075.00 Sq.Ft
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:09/25/2015 Number of Sheets:2
Cafeteria:
. Tit1e:PLOT PLAN OF PROPOSED SEPTIC SYSTEM UPGRADE 19 NORTH Revision Date: 10/12/2015
SANDYSIDE LANE
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:444.52 gpd
' Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:06/04/2015
CA
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,20
HIGH CAPACITY H-20 INFILTRATORS W/OUT STONE:31.75'X 12.83'X 11°
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 Heakh.
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;
SHAY ENVIRONMENTAL, P.O. BOX 1576, MASHPEE, MA 02649
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To perform:Upgrade an individual sewage disposal system.
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Owner: ALBERTI RALPH C TRS
� ALBERTIFLORENCE M
19 N SANDYSIDE LN
YARMOUTH PORT,MA 02675-1750
Location: 19 NORTH SANDYSIDE LN,YARMOUTH PORT,MA 02675
Disposal System Construction Permit No.: BOHDC-15-5541 ,Dated:November 04,2015
Provided: Construction shail 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, DBOX,20 HIGH CAPACITY H-20
INFILTRATORS W/OUT STONE: 31.75'X 12.83'X 11"
2. MFC VARIANCE APPROVAL:a. DEPTH OF LEACH FACILITY
U(�"�l
Bruce G. Murph , R.S., CHO/Amy L.von Hone, R.S.,CHO
H th 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 $55.00
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� Description of Work:Individual Component(s)
� The undersigned hereby certify that the Sewage Disposal System; Upgraded
{
I by: SHAY ENVIRONMENTAL
� at: 19 NORTH SANDYSIDE LN,YARMOUTH PORT,MA 02675
� 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-15-5541,dated 11/13/2015.
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� Installer: SHAY ENVIRONMENTAL
� Address:P.O.BOX 1576 MASHPEE,MA 02649 Inspector:AMY VON HONE,R.S.
Designer:CARMEN E. SHAY ENVIRONMENTAL
SERVICES
� Conditions
' 1.SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,20 HIGH
CAPACIT'Y H-20 INFILTRATORS W/OUT STONE:31.75'X 12.83'X 11"
� 2.MFC VARIANCE APPROVAL:a.DEPTH OF LEACH FACIL ��
I
IBruce G. Murph ,M H, 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