HomeMy WebLinkAboutApp-Permit-Compliance60woc-15- 571POS- &
COMMONWEALTH EALTH Ojt' MASSAC14lJSET S
Board of Health, YARMOUTH HEALT1146 ROUTE 28 H DER'.
APPLICATION FOP DISP0 QAW,'K*)WRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
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Location2-,,, N Law.
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's Name ' e
En Ownerwia�
Map/Parcel# 62-3,113
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Address ' 111 y� 1e r 1 A I
' V H -
Lot#
Telephone# - I
Installer's Name . W , ' n c .
Designer's Name
Address `Address
Telephone# SulkTelephone#
Type of Building ampwym Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersign ees to install theAbove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t t to Tace the e o ration until a Certificate of C n!plian a has been issued by the Board of Health.
Signed Date 2
Inspections
No. BOWD G 115-5%4 0
Boardl'of Health, YAAM n VfI4 MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby cert �that the Sewage Disposal ,S stem; Constructed O R�aired ( U&14raddd �Aba
by:
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has been installed nYKordarice w tlTt
application No. % -4- b dated
Installer
FEE t S6-
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CA,* 27VI
vi ion of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
'Approved Design. Flow "-""""' (gpd)
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gu tee that the system will function as designed.
No.JCj� ®Ej t . W a N 1 c4csorj FEE 00
COMMONWLAL114 Of MASSACHUSETTS
Board of Health, YAA2 M a V_rl i MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade ( ) Abandon( ) an individual sewage disposal system
at �Z 5 XD %J (-AN E as described in the application for
Disposal System Construction Permit No. Sr_ '� `bdated /0 -,4-1,'_
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Provided: Construction shall be complete witf the date of this per it. All local on' itions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date o d of Health
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No.:BOHDC-15-5405
Commonwealth of Massachusetts Fee
ass.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Repair-minor-Individual Component(s)
Location:2 SANDY LN,WEST YARMOUTH, MA 02673 Owner:
MCLAUGHLIN MAURA F TRS
Map/Parcel#: 023.113 C/O ANNE FLANNERY
11 HICKORY LANE
FARMINGTON,CT 06032-1905
Phone:
Septic System Installer Desigaer
T.W.NICKERSON,INC.
160 MILL HILL ROAD SOUTH
CHATHAM, MA 02659
Phone:
Type of Building:Dwelling Lot Size: 14,375.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fiatures:
Plan Date: Number of S6eets: Cafeteria:
Title: Revision Date:
Design Flow(min.required):220 gpd Calculated design flow:220 gpd Design flow provided:489 gpd
Description of Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-FILL ABANDONED CESSPOOL,REPAIR
INLET AND OUTLET TEES IN EXISTING 1000 GAL SEPTIC TANK SERVICING DBOX AND 4'LEACH PIT W/3'STONE PER
INSPECTION REPORT
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 un81 a Certificate of Comoliance has been issued bv the Board of Heakh.
Signed Date
Inspections
y Y
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
T.W. NICKERSON, INC., 160 MILL HILL ROAD, SOUTH CHATHAM, MA 02659
To perform:Repair-minor an individual sewage disposal system.
Owner: MCLAUGHLIN MAURA F TRS
C/O ANNE FLANNERY
11 HICKORY LANE
FARMINGTON,CT 06032-1905
Location:2 SANDY LN,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-5405,Dated:October 28,2015
Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met.
CONDITIONS:
1.SEPTIC DISPOSAL-MINOR REPAIR-FILL ABANDONED CESSPOOL, REPAIR INLET AND OUTLET TEES
IN EXISTING 1000 GAL SEPTIC TANK SERVICING DBOX AND 4'LEACH PIT W/3'STONE PER INSPECTION
REPORT
�,
Bruce G. M ph ,MPH, R.S., CHO/Amy L.von Hone, R.S., CHO
Health Director/Assistant Health Director
The issuance of this permit s6a11 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
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' CERTIFICATE OF COMPLIANCE ass.00 '
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� Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Repair-minor
by:T.W.NICKERSON,INC. ��
at:2 SANDY LN, WEST YARMOUTH,MA 02673 ,I
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-15-5405,dated 11/02/2015.
Installer:T.W.NICKERSON,INC.
Address:160 MILL HILL ROAD SOUTH CHATHAM, Inspector:AMY VON HONE,R.S.
MA 02659
Designer:
Conditions
1.SEPTIC DISPOSAL-MINOR REPAIIt-FILL ABANDONED CESSPOOL,REPAIIt INLET
AND OUTLET TEES IN EXISTING 1000 GAL SEPTIC TANK SERVI ING DBOX AND 4'
LEACH PIT W/3'STONE PER INSPECTION REPORT ��
Bruce G. Murp , M H, R.S., CHO/Amy L.v n 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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