HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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COMMONWEALTH OF MASSACHUSETTS Ct-WZ5,2,j
Board of Health, vl A-amoo7u , MA.
APPLICATION FOR 1!� �P® L SYSTEM CONSTRUCTION ERM IT
plication fora Permit to Construct( ) Repair( UpgradeO Abandon( - ❑ Complete System Individual Components
Location Z,
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Owner's Name Q 1
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
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Designer's Name
Address �Q .
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Address
Telephone# 53
7 ? 500
Telephone#
Type of Building K -e S
Dwelling - No. of Bedrooms _
Other - Type of Building
Other Fixtures
Design Flow (min. required) _
PIan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
OF
gpd Calculated design flow
Number of sheets
OR ALTERATIONS
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
_ Garbage grinder( }
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
The undersign 4eesttall th cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreethe s operation until a Certificate of Compliance bas been issued by the Board of Health.
Signed / Date
Inspections
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bonc -� 5--5u q C®�[MONWEA1LT14 OF MASS CHUSETT
Board of Health, j"a- , MA.
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CERTIFICATES Of COMPLIANCE � lew
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal Sy tem; Constructed ( ), Repaired ), Upgraded ( ), Abandoned ( )
by:('a�X, CUt �� (C
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has been installed`in'V
application No.sr ..
Installer 7b .0 C,c �i.
With Ti vXions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated Approved Design Flow (gpd)
Designer: -�"' Inspector: Date: i !:4(_
The issuance of this permit shall not be construed as a guaa,44 that the system will function as designed.
/S COMMONWEALTH OF MASSACHUSETTS
Board of Health, t4iM nt MA.
DISPOSAL SYSTEM BON PERMIT
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Permission is hereby granted to; Construct( �) Repair ) Upgrade( ) Abandon-( ) an individual sewage disposal system
at . t k�l as described in the application for
Disposal System Construction Permit No./�.�-,dated //' ,6
Provided: Construction shall be & Mite Z thin aaL of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Dat,//—G Boarf of Health
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No.:BOHDC-15-5629
Commonwealth of Massachusetts Fee
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
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� Application for a Permit to:Repair-minor-Individual Component(s)
! Location: 26 TALL PINES DR,YARMOUTH, MA 02675 Owner:
LOMBARDIKENNETH
{ Map/Parcel#: 117.20 LOMBARDI M A L M N A
i 270 CROSS ST
BOYLSTON,MA 01505
Phone:
� Septic System Installer Designer
! BEFORE SUNSET LLC
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P.O. BOX 1466 HARWICH, MA 02645
Phone:
; 5082402500
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Type of Building:Dwelling Lot Size: 16,553.00 Sq.Ft.
Dwelling-No.of Bedrooms:3 Garbage Grinder:
; Other Type of Building: No.of persons: Showers:
' Other Fixtures:
Plan Date: Number of Sheets:
Cafeteria:
Title: Revision Date:
, Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:330 gpd
Description of Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MINOR REPAIR-REPALCE OUTLET TEE AND DBOX PER
INSPECTION REPORT
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 6een issued bv the Board of Heakh.
Signed Date
Inspections
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Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPO5AL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
� BEFORE SUNSET LLC, P.O. BOX 1466, HARWICH,MA 02645
; To perform:Repair-minor an individual sewage disposal system.
Owner: LOMBARDI KENNETH
LOMBARDI M A L M N A
270 CROSS ST
BOYLSTON,MA 01505
Location:26 TALL PINES DR,YARMOUTH,MA 02675
Disposal System Construction Permit No.:BOHDGIS-5629,Dated:November 06,2015
Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met.
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CONDITIONS:
1. SEPTIC DISPOSAL-MINOR REPAIR-REPALCE OUTLET TEE AND DBOX TO EXISTING 1000 GAL SEPTIC
TANK AND LEACH FIELD PER INSPECTION REPORT
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1 Bruce G. Murp , PH, R.S., CHO/Amy L.von Hone, R.S.,CHO
� �alth 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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