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HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH SOF MASSACHUSETTS Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N F FEE 16'S ' SEP 212015 HEALTH DEPT. Application for a Permit to Construct( ) Repair �pgrade ( ) Abandon( ) - ❑ Complete System O Individual Components Location 16 TW Owner's Name n h 5 Map/Parcel# Address A4411 Lot# Telephone# %66`--s 2 - L- e Installer's Name 0 Designer's Name Address 2L r,**w e6 -*e n Address Telephone# EDF—SO Telephone# Type of Building fe-S 1 d e-^ fiA-I Lot Size sq. ft. Dwelling - No. of Bedrooms 1cL- ire rg-A- Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soils) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS c. k TO J_e� Pi Ir Design flow provided Revision Date Date of Evaluation gpd 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 pl a thi tem in operation until a Certificate of©Compliance has been issued by the Board of Health. Signed �`rtXC�.. Z Date Inspections No. bo W -D C — r S —L/472, COMMON LTH OF MASSACHUSETTS FEE 0 % x-00 gcai� Board of Health, Y{y�<1[lTi-( , MA. CERTIFICi Of COMPLIANCE t°`�'� .S_, ,� r�,�f Description of Work: "Sll%dividual Component(s) ❑ Complete System y�%% f �t� 1,e .s The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (K, Upgraded ( ), Abandoned ( by: F.Q-fW-., i—V 6,C-14.91- a> A- k i C at "' r"l.%✓'yld-v� ,v'A _ has been installe� n aE`cord'ar ce wiry ��stons of 310 CMR 15.00 Title 5 and the roved design Tans/as-built plans relating to 1�° .. ( ) PP g P P g application No.dated / .Approved Design Flow -- (gpd) Installer Designer: Inspector: �.t 1 ry iLjP- 7Date: ' i� "P• The issuance of this permit shall not be construed as a guarante/that the system will function as designed. s L-.. tom.-. C tCt_:.1:- i'[,._,':rLt__.L.'•C.�= f No: C)OZ g- Co. . FEE JS�, 0 d -2 ' COMMONWEALTH Of MASSACHUSETTS Board of Health, Y"-.04 n nok , MA. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(VI Upgrade( ) Abandon( ) an individual sewage disposal system at �� U AA& °'ti L4,k • as described in the application for Disposal System Construction Permit No. 1Z, dated Provided: Construction shall be comp eted wt to t rre ear's o�fk date of this permit. All local conditions must be met. _ 6 f'--0� �� � f �- j j/ i i Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date -.2 I'�z Board of Health t (. %tJ •- �' Y t� r 1 t`/� <�,,. � • � I � No.:BOHDGIS-4472 , Commonwealth of Massachusetts Fee ass.00 Board of Health, Yarmouth, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERIVIIT 1 Application for a Permit to:Repair-minor-Individual Component(s) Location: 16 TRUMAN LN,WEST YARMOUTH, MA 02673 Owner: SAUNDERS DOUGLAS L JR Map/Parcel#: 058.132 SAiJNDERS ANNE E 41 FARRINGTON ST FRANKLIN,MA 02038 ' Phone: i � Septic System Installer Designer i � ROBERT B.OUR P.O. BOX 1539 HARWICH, MA 02643 Phone: � � Type of Building:Dwelling Lot Size: 13,068.00 Acres I Dwelling-No.of Bedrooms:3 Garbage Grinder: i � Other Type of Building: No.of persons: Showers: i Other Fixtures: Plan Date: Number of Sheets: Cafeteris• 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-REPLACE ORANGEBURG PIPE BETWEEN EXISTING SEPTIC TANK AND LEACH PIT PER INSPECTION REPORT 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 Comoliance has been issued bv the Board of Health. � Signed Date � Inspections :� � . , � � � � Commonwealth of Massachusetts Board of Health, Yarmouth, MA Fee DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00 j 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: SAUNDERS DOUGLAS L JR { SAUNDERS ANNE E � 41 FARRINGTON ST FRANKLIN,MA 02038 Location: 16 TRUMAN LN,WEST YARMOUTH,MA 02673 ' Disposal System Construction Permit No.: BOHDC-15-4472 ,Dated:September 21,2015 JProvided:Construction shall be completed within six months of the date of this permit. All local conditions must be met. iCONDITIONS: � SEPTIC DISPOSAL-MINOR REPAIR-REPLACE ORANGEBURG PIPE BETWEEN EXISTING SEPTIC TANK � AND LEACH PIT PER INSPECTION REPORT 2015 � �� i � l�1 Bruce G. rph ,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. ! � i � i , � , ,�. i � � Commonwealth of Massachusetts Board of Health, Yarmouth, MA Fee CERTIFICATE OF COMPLIANCE S55.00 + Description of Work:Individual Component(s) � The undersigned hereby certify that the Sewage Disposal System; Repair-minor j by:ROBERT B.OUR COMPANY INC. j at: 16 TRUMAN LN,WEST YARMOUTH,MA 02673 i 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-15-4472,dated 09/23/2015. � � Installer:ROBERT B.OUR COMPANY INC. � � Address:P.O.BOX 1539 HARWICH,MA 02643 Inspector:AMY VON HONE,R.S. a � Designer: � i � , V C'`7 � Bruce G. Mur , MPH, R.S. CHO/Am L.von Hone R.S. CHO Y , Y � � Health Director/Assistant Health Director i 1 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. � ; i � a BOH_Disposal_Construction_CofC.rpt � � ,, i 1 ;