HomeMy WebLinkAboutApp-Permit-ComplianceNo. �� a C - IS �3 L b Tel ✓ 16 - ��7 Z �/ 77 FEE L519 00 p
COMMONWEALTH LTH /®f MASSACHUSETTS
Board of Health, �yA'&:M 007W , Mm -
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(` (Abandon( ) - 0 Complete System 0 Individual Components
Location + V (1
Owner's Name 4
� 6X
Map/Parcel# -35 &Y
Address ZI S(ji tl aA
rjtr7t ��
Lot# /
Telephone# 721-
- I Zq
Installer's NameAo t &j -r- , Xf Y,
Designer's Name
ver
Address 2 �
Address A0- Sam 463
be-nni'S �
_ 0 _
Telephone# 6� l9s
Telephone# L&CF 3
- oYff
Type of Building ke6 de., �Q � Lot Size A Lall sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) n Q gpd Calculated design flow Design flow provided 3 4A7 gpd
Plan: Date /0- -d)Number of sheets Revision Date
Title 21 vi It' 1liLat M.
Description of Soil(s) 7,� oay Steiei `�6 A�Pl�tll-w-/��
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 �o pl'ace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed -��3 / ' f + ftayajlle Date lis "'
Inspections
No. �" �S� FEE. 00
is o COMMONWEALTH Of M ASSACHUSETTS *-00700E
Board of Health, �fl'12/1� OUN , MA. ,
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) boComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (� Abandoned( )
by: f- JF 0V(- Leo. %T Y)G .
at c� A 5Ui{iJGat i }
has been installed r�eordance with the provisions of 310 CMR 15.00 (Title 5and th,approved design plans/as-built plans relating to
application No. 1� L �� dated /� %% . Approved Design Flot (gpd)
Installer /` Ri - 4 0 CD& *A le- / AC. ,r
Designer: B RI'VGC 464'5 Inspector: Date:
The issuance of this permit shall not be construed as a guar a that the system will function as designed
C OJ 0000J30J '):�:2.^GC O:J_OOC.,DOJO=�>-�C�^'iC^060-Ot 11 C 0 O 00100„0000Q ..0 0 O OOC100000000- 00 O 0100 O 000 O 00. 000 OO JO 0 O O O CC'
No. ��U�"(g — � � 00CL Co. FEE C"4 . 00
COMM ON 4LT14 Of MASSACHUSETTS ek*00 Z8
Board of Health, yt►�atr�l' , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at 'Zi 5 V 1 i i V e.. r -,,r' as described in the application for
Disposal System Construction Permit No./�r dated
3
Provided: Construction shall be comp c�wtthin thTer-vew-i of the date of this permitt,. All local conditions must be met.
av
Form 1255 Rev. 5/96 A.M. SU.Ikin Co. Chadestown, MA Date ��� Board of Health
� No.:BOHDGIS-5413
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: 21 SULLIVAN RD,WEST YARMOUTH, MA 02673 Owner:
SHEA MICHAEL
Map/Parcel#: 039.105 SHEA DIANNE
21 SULLIVAN RD
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
ROBERT B.OUR BASS RIVER ENGINEERING
P.O. BOX 1539 HARWICH, MA 02643 P.O.BOX 1163
Phone: EAST DENNIS,MA 02641
5085094058 508-385-3426
Type of Building:Dwelling Lot Size: 17,424.00 Sq.Ft.
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date: 10/09/2015 Number of Sheets: 1 Cafeteria•
, Title:SITE PLAN 21 SULLIVAN ROAD Revision Date:
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:349 gpd
, Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: 10/07/2015
THOMAS MCLELLAN,P.E.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,2-
500 GAL PRECAST CHAMBERS W/4'STONE:25'X 12.8'X 2'
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 Comoliance has been issued bv the Board of Heakh.
Signed Date
Inspections
,II
Commonwealth of Massachusetts
• Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
ROBERT B. OUR COMPANY INC., P.O. BOX 1539, HARWICH,MA 02643
To perform:Upgrade an individual sewage disposal system.
Owner: SHEA MICHAEL
SHEA DIANNE
21 SULLIVAN RD
WEST YARMOUTH,MA 02673
Location:21 SULLIVAN RD,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-5413 ,Dated:November 09,2015
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 SEPTIC TANK, DBOX,2-500 GAL PRECAST ;
CHAMBERS W/4'STONE:25'X 12.8'X 2'
U
Bruce . Murphy,MPH, R.S., C O/Amy L.von Hone, R.S., CHO
Health Director/Assistant Heaith 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 S55.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:ROBERT B.OUR COMPANY INC.
at:21 SULLIVAN RD,WEST YARMOUTH,MA 02673
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-15-5413,dated 12/Ol/2015.
Installer:ROBERT B.OUR COMPANY INC.
Address:P.O.BOX 1539 HARWICH,MA 02643 Inspector:AMY VON HONE,R.S.
Designer:BASS RIVER ENGINEERING
Conditions
1.SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,2-500 GAL '
PRECAST CHAMBERS W/4'STONE:25'X 12.8'X 2' ��
Bruce . rphy,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
I