App-Permit-Compliance13u rn -« -00 t s q'2�
No. /yd bt [)C /51 55THE COMMONWEALTH OF MASSACHUSETTS FEE �6600
BOARD OF HEALTH
APPLICATION FOR DISPOSAL SYSS-EM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( Abandon ( )-..215omplete System ❑ Individual Components
0Imo M01S ��_To_
3 O Location—z —7
Map/Parcel #
Lot #
�:ANl�IZ �n.nlS..j �t/CT/t�/✓
-4& GIZOIWe Installer'sNameme ��, F L
So dre, _ 753
Telephone #
Type of Building: VE S
Dwelling — No. of Bedrooms
Other — Type of Building No. of persons
Other fixtures
`_jc I<=f-0e"D
14 `y� M 0w .er's N:ry -�
L%�/H"�'1J 1 �CtAdddress �/
? 27- 2u 4- (o¢3s
2 � Telephone # M�y�z.
�— Des? ner's Name
f £.SANI�WICN MA
Address
®2� 3-7 g)_ ?60 331/
Telephone #
Lot Size . Z-fA Sq. feet
Garbage Grinder ( )
Showers ( ), Cafeteria
Design Flow (min. required) 3, 6 gpd Calculated des>g -350 gpd Design flow provided 33 6 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator 101116-Y60 Date of Evaluation
DESCRIPTION OF REPAIRS QR ALTERATIONS �!'Cp/GK{ Eft S t f/VH CrSS vo c l')
N,rw' /Soo A�10 Sra1ic Ti /L li o 71 lax �.W /_ 6ha4ikeAr
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agr of to pjace4kV system in operation until a Certificate of Compliance has beeni uuedb the Board of Health.
Signed / Date / js
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
`— uy r
No ffjpc 'V—gge6THE COMMONWEALTH OF MASSACHUSETTS
� FEE
Y"&,Oyrj t BOARD O F HEALTH �-3 r—(j
CERTIFICATE OF COMPLIANCE. Kie I�--
Description of Work: E] Individual Component(s) �mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (4,upgraded ( ), Abandoned ( )t
by:
at
has been installed in accordance with theprovisions of 310 CMR 15.00 (Title 5) and the approved design lans/as-built
plans relating to application No. A - dated 14 Approved Design Flow (gpd)
Installer.wN,c.,...�+
Designer: �DY% c Inspector Date lv 5
The issuance of this certificate shall not be construed as a guaran a that the system will function as de gned.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 6Q( L/S WfgQHE COMMONWEALTH OF MASSACHUSETTS FEE
2 --> `• %.OU+I F' BOARD OF HEALTH 3
Permission is
disposal system at I
DISPOSAL SYSTEM CONST UCTION PERMIT
hereby granted to, Construct, ( ) Repair (4�grade ( ) Abandon ( ) an i
in the application for Disposal System Construction Permit No.
Provided: Construction shall be completed within tk
Date I Aj r <_-/
FORM 2 - DSCP
DEP APPROVED FORM 5/96
ndividual sewage
as described
�j ated /G-
ae oT tthis per>hi ll local conditions must be met.
Boardof Health
FORM 1255 (REV 5/96) H&W Homs& WARREN TM PUBLISHERS - BOSTON
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No.:BOHDC-15-4488
' Commonwealth of Massachusetts Fee
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
� Location: 14 THOMAS PATH,WEST YARMOUTH, MA 02673 Owner:
�
� PICKFORD ROBERT C
Map/Parcel#:030.227 PICKFORD ELIZABETH A
31 ISLAND WAY SUITE 1507
CLEARWATER,FL 33767
Phone:
1 Septic System Installer Designer
` RANGER MEYER&SONS,INC.
� 46 CROWELL ROAD EAST P.O.BOX 981
FALMOUTH, MA 02536 EAST SANDWICH,MA 02637
Phone:
508-360-3311
Type of Building:Dwelling Lot Size: 12,632.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder•
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:09/27/2015 Number of Sheets•2 Cafeteria:
Tit1e:SEPTIC SYSTEM REPAIR PLAN 14 THOMAS PATH Revision Date:
Design Flow(min.required):220 gpd Calculated design flow:220 gpd Design flow provided:336 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:09/17/2015
DARREN MEYER,R.S.
. DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,H-20 DBOX,
24 INFILTRATOR QUICK 4 STANDARD LOW PROFILE UNITS W/OUT STONE:24'X 11.32'X 3.3"
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 Certiflcate of Comoliance has been issued bv the Board of Heakh.
Signed Date
Inspections
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, Commonwealth of Massachusetts
; Board of Health, Yarmouth, � Fee
� DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
RANGER CONSTRUCTION,46 CROWELL ROAD, EAST FALMOUTH, MA 02536
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To perform:Upgrade an individual sewage disposal system.
Owner: PICKFORD ROBERT C
PICKFORD ELIZABETH A
31 ISLAND WAY SUITE 1507
CLEARWATER,FL 33767
Location: 14 THOMAS PATH,WEST YARMOUTH,MA 02673
� Disposal System Construction Permit No.: BOHDC-15-4488,Dated:October O5,2015
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, H-20 DBOX,24 INFILTRATOR QUICK
4 STANDARD LOW PROFILE UNITS W/OUT STONE:24'X 11.32'X 3.3"
Bruce G. Murphy P , R.S., CHO/Amy L.von Hone, R.S.,CHO
H th 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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� Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
' CERTIFICATE OF COMPLIANCE $55.00
�
�� Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
i
; by:RANGER CONSTRUCTION
,
at: 14 THOMAS PATH,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-15-4488,dated 10/15/2015.
? Installer:RANGER CONSTRUCTION
Address:46 CROWELL ROAD EAST FALMOUTH, Inspector:PHILIP RENAUD
i MA 02536
� Designer:MEYER&SONS,INC.
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Bruce G. Murp , M H, 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.
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BOH_Disposal_Construction_CofC.rpt
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