HomeMy WebLinkAboutApp-Permit-ComplianceNo. rr*Dr-'I5--3®x{8 THE COMMONWEALTH OF MASSACHUSETTS E �Er—'--_
17 BOARD OF HEALTH Dt+ 2�
�yu3� OF
APPLICATION FOR DISPOS SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( pgrade ( ) Abandon ( ) -omplete System ❑ Individual Components
Location
,, Tarcel #
i
Lot #
Name
Telephone #
Owner's Name
Address
Address
Telephone #
Type of Building: Lot Size Sq. feet
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria
Other fixtures I .
Design Flow (mij. req'red) 4,
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR
gpd Calculated design flow
Number of sheets
Name of Soil
gpd Design flow
Date of
gpd
The unders' ned agrees to i tall the above described Individu Se age Disposal System in accordance with the provisions of
TITLE 5 and fu r agrees not to c the syste opera' n until a cate of Compliance has be iss ed by the Board of Health.
Signed Date1 �� V
Inspections
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No. 1304-iS-3o�t� THE COMMONW ALTH OF MASSACHUSETTS FEE 00
BOARD OF HEALTH
CERTIFICATE OF CONMANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Con tructed ( ), Repaired ( ), Upgraded V5/,Abandoned ( )
at I t 4 % I
has been 'nst ed in accord nc ith the pr visi ns of 310 CMR 1b.00 (Title 5) and the approved desi laps/as-built
plans rel t ti�aZWIEatio2i 7 dated F `/ Approved Design Flow=(gpd)
Installer L :rl' c DN *L/ I0CLq5W-QC!7P4
Designer: "DAQ Q) @/ . H jam, c LJ Inspector � ;`5 Date
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. 60-DC-45--304BTHE COMMONWEALTH OF MASSACHUSETTS FEE If CJs7LQV
QP ' .y�,c , �� /7� �ti BOARD OF HEALTH -Z-1�
DISPOSAL SYSTEM CONSTRUCTIPERMIT
Permission is hereby gragtpd tg_gpnnstruct ( ,) &paiir 1 __)„J,Ipgrade ( Abandon ( ) an individual sewage
disposal system at
in the application for Disposal System
Provided: Construction shall be completed withia thp&@-yeax���'oof'hh�e'' date of fh
Date — �� �� (064//oafd of Health
FORM 2 - DSCP
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON
as described
dated C—/�; /�—
No.:BOHDGIS-3048
� Commonwealth of Massachusetts Fee
ass.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System '
Location: 11 EDDY ST,WEST YARMOUTH, MA 02673 Owner:
BALBONI MARY E
Map/Parcel#: 037.6.1 11 EDDY ST
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
CARDINAL DAVID B.MASON,R.S.
32 RIDGETOP ROAD COTUIT, MA 4 GLACIER PATH
02635 EAST SANDWICH,MA 02537
Phone: 508-833-2177
Type of Building:Dwelling Lot Size:28,750.00 Acres
Dwelling-No.of Bedrooms:4 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures: '
Plan Date:07/27/2015 Number of Sheets: 1
Cafeteria:
Tit1e:SITE AND SEWAGE PLAN 11 EDDY STREET Revision Date: I
f
Design Flow(min.required):440 gpd Calculated design flow:440 gpd Design flow provided:455 gpd i
Description of Soi1s:SEE PLAN �
a
' Soil Evaluator Form No.: Naroe of Soil Evaluator: Date of Evaluation:07/08/2015 �
DAVID B.MASON,R.S.
I
• DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL TWO COMPARTMENT
SEPTIC TANK,DBOX,3-500 GAL PRECAST CHAMBERS W/4'STONE:33.5'X 12.83'X 2'
i
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 Comnliance has been issued 6v the Board of Health.
Signed Date I
Inspections ;
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• Commonwealth of Massachusetts
p Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is hereby granted to;
CARDINAL CONSTRUCTION, 32 RIDGETOP ROAD, COTUIT, MA 02635
To perform: Upgrade an individual sewage disposal system.
Owner: BALBONI MARY E
11 EDDY ST
WEST YARMOUTH,MA 02673
Location: 11 EDDY ST, WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-3048 ,Dated: August 19,2015
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 TWO COMPARTMENT SEPTIC TANK,
DBOX, 3-500 GAL PRECAST CHAMBERS W/4'STONE: 33.5'X 12.83'X 2'
����
Bruce G. Mu y, PH, R.S., CHO/Amy L. von Hone, R.S., CHO ;
Health Director/Assistant Health Director '
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- The issuance of this permit shall not be construed as a guarantee that the system will function as designe i
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