HomeMy WebLinkAboutApp-Permit-ComplianceNo.i�
COMMONWEALTH OF MASSACHUSETTS c t-2,Pz
Board of Health,d urg
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade�_KAbandon( ) - -0omplete System ❑ Individual Components
Location
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Owner's Name j i OSI, i
Map/Parcel#
3
Address
Lot#
Telephone# (p j "? 7 C—a 0--7
Installer's Name
jjl�Co�LS'd�
Designer's Name
Address a s
j (r r i i �
Address � 3
Telephone#
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Telephone# S 3 Z —11
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
l gpd Calculated design flow Design flow provided gpd
Plan: Date V i l ) O J S Number of sheets i Revision Date
Title
Description of Soil(s) 'Sez" S6,
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton 1` a thet
ti n until a Certificate of Compliance has been issued by the Board of Health.
further agrees t�o �nSigned L" �� Date
Inspections
COMMONWEALT14 OF MASSAC14USETTS
Board of Health, "MQ Ur-)+ , MA.
CERTIFICATE OF COMPLIANCE
FEE S37
2,
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: I 1 �s 6 f a D-4 f 5 C C. i,), J -
at 'Vc, (c f r r,-, L.�
fi5 m c } -- -
has been installed in ac oRan e with the rovisions of 310- CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �. I.r ? dated , —30 Approved Design Flow(gpd)
Installer
N
Designer: 1)Qt.n g izApnpti Inspector: Date: " T- / `7
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
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No. �� Z�✓I i_"'�-t-1 S (jeers, FEE l`1 d0
�`- COMMONWEALTH Of MASSAC14USETTS ck 02 -6 -0Z -
Board of Health,.,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade.F--Y'Abandon( ) an individual sewage disposal system
at L/,j Cti , C L ti{J�as described in the application for
Disposal System Construction Permit No. / / > datedZ� '
Provided: Construction shall be completed within three _lz arse the date of this peppi . All local conditions must be met.
fir;
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date b �:Board of Health
No.:BOHDC-15-2518
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: 25 VACATION LN,WEST YARMOUTH, MA 02673 Owner:
JOSHI ADITI
Map/Parcel#: 039.54 25 VACATION LANE
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
ELLIS BROTHERS DOWN CAPE ENGINEERING,INC.
PO BOX 59 YARMOUTHPORT, MA 939 ROUTE 6A
02675 YARMOUTHPORT,MA 02675
Phone: 508-362-4541
Type of Building:Dwelling Lot Size:9,583.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: No.of persons: Showers: '
Other Fixtures:
Plan Date:06/O1/2015 Number of S6eets: 1 Cafeteria•
Tit1e:TITLE 5 SITE PLAN 25 VACATION LANE Revision Date:06/26/2015
Design Flow(min.required):220 gpd Calculated design tlow:220 gpd Design flow provided:349 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:OS/27/2015
DANIEL GONSALVES,SE
. DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-PROPOSED PLASTIC 1500 GAL SEPTIC TANK,DBOX, 16 HIGH
CAPACITY INFILTRATORS W/OUT STONE IN FIELD CONFIGURATION
� 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 oneration until a Certificate of Comoliance has been issued bv the Board of Health.
Signed Date
Inspections
i
i
� Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
ELLIS BROTHERS CONSTRUCTION, PO BOX 59,YARMOUTHPORT, MA 02675
To perform:Upgrade an individual sewage disposal system.
Owner: JOSHI ADITI
25 VACATION LANE
WEST YARMOUTH,MA 02673
Location:25 VACATION LN,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-2518,Dated:June 30,2015
Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions
1. REPAIR-PROPOSED PLASTIC 1 S00 GAL SEPTIC TANK, DBOX, 16 HIGH CAPACI7'Y
INFILTRATORS W/OUT STONE IN FIELD CONFIGURATION
2. MFC VARIANCE.•A. SETBACKS
�v �
Bruce G. M hy, PH, R.S., CHO/Amy L.von Hone, R.S., CHO
ealth Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarantee that the system will functioa as designed.
�
I
�
Commonwealth of Massachusetts
; Board of Health, Yarmouth, MA Fee
�
i CERTIFICATE OF COMPLIANCE $55.00
I
Description of Wark:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:ELLIS BROTHERS CONSTRUCTION
at:25 VACATION LN, 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-15-2518,dated 07/14/2015.
Installer:ELLIS BROTHERS CONSTRUCTION
Address:PO BOX 59 YARMOUTHPORT,MA 02675 Inspector:AMY VON HONE,R.S.
Designer:DOWN CAPE ENGINEERING,INC.
Conditions
1.REPAIR-PROPOSED PLASTIC 1500 GAL SEPTIC TANK,DBOX,16 HIGH CAPACITY
INFILTRATORS W/OUT STONE IN FIELD CONFIGURATION
2.MFC VARIANCE:A.SETBACKS � `. ,
l�
Bruce G. urph , 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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