HomeMy WebLinkAboutApp-Permit-Compliance46�
No. 1b0WDC -15—Z579 /` v t( ` " FEE 55, 00
COMMONWEALTH Of MAS AC14USETTS
Board of Health, yah ouna , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair NrUpgrade ( ) Abandon( ) - ❑ Complete System 0 Individual Components
Location Z2-'+a,+ioA Ave
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name RnT �? 0.
Designer's Name
Address 24 6r1?0-+W1a5 n
Address
Telephone# Sal- 500-L105,9Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
gpd Calculated design flow
Number of sheets
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date _ __
gpd
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ht' -:AMM Q M D Bo Q Y\ 1 (.t
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. 6044pG �4 ? . A EE
COMMONWEALTH Of MASSACHUSETTS ��, is ��s-72
oat
Board of Health, /�s.a'�IZi tilt -4 , Am.� /,
CERTIFICATE Of C®MPLIANC�
Description of Work: gindividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired , Upgraded ( ), Abandoned ( )
by: (a.(3 � 3, ovr Ccs . rAC
has been installe in accordance with the rovi ions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ���/� 7, dated e _ 'g % Approved Design Flow (gpd)
Installer 9()ketT &u- Co, f�G, " C4K1-15TDPt �. (ti}, 00 - _ _____----
Designer: Inspector: Date: /
The issuance of this permit shall not be construed as a guar e tht the system will function as designed.
No. 0 C-;'S-Zi7 (ZIaI oU(z-Co,
COMMONWEALTH OF MASSACHUSETTS
Board of Health, \/A-eMQQ-M , MA.
DISPOSALDISPOSALS SYSTEM CONSTRUCTION PERMIT
FEE
cid 00('87Z -
Permission is hereby
, granted to; Construct( ) Repair Upgrade ( ) Abandon( ) an individual sewage disposal system
at ZZ S - 1 ! o n A VIE as described in the application for
Disposal System Construction Permit No. , dated X75-
�� ��
Provided: Construction shall be cofifpleted within yrs 6f the dw of this permit. AIL -local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date �' lBoard of Health
� ,
No.:BOHDGIS-2579
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: 22 STATION AVE, SOUTH YARMOUTH, MA 02664 Owner:
THOMAS CHRISTOPHER G
Map/Parcel#: 070.7 THOMAS NANCY M
130 WARREN ST
NEEDHAM,MA 02192-3029
Phone:
Septic System Installer Designer
�
ROBERT B.OUR
P.O. BOX 1539 HARWICH, MA 02643 '
Phone:
Type of Building:Dwelling Lot Size:9,148.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
i
Other Type of Buiiding: No.of persons: Showers: �
Ot6er Fixtures: '
Plan Date: Number of 56eets: Cafeteria•
Title: Revision Date:
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:330 gpd
i
Description of Soils: '
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: �
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX PER INSPECTION �
REPORT DAT`ED 07/17/2015
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
i
i
i
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is herby granted to;
ROBERT B. OUR COMPANY INC., P.O. BOX 1539, HARWICH, MA 02643 '
To perform: Repair-minor an individual sewage disposal system.
Owner: THOMAS CHRISTOPHER G
THOMAS NANCY M
130 WARREN ST
NEEDHAM,MA 02192-3029
Location: 22 STATION AVE, SOUTH YARMOUTH, MA 02664 'i
Disposal System Construction Permit No.: BOHDC-15-2579 ,Dated: August 04,2015 ;
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
CONDITIONS: '
1. MINOR REPAIR-REPLACE DBOX PER INSPECTION REPORT DATED ;
07/17/2015 i
- ��
Bruce G. Murphy,.�IVIPH, R.S., CHO/Amy L. von Hone, R.S., CHO '
He��th Director/Assistant Health Director '
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. ;
�
;
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; Repair-minor
by:ROBERT B.OUR COMPANY INC.
at:22 STATION AVE,SOUTH YARMOUTH,MA 02664
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-15-2579,dated 08/OS/2015.
Installer:ROBERT B.OUR COMPANY INC.
Address:P.O.BOX 1539 HARWICH,MA 02643 Inspector:AMY VON HONE,R.S.
Designer: '
l./
Bruce G. rp y,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.
BOH_Disposal_Construction_CofC.rpt ,
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