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HomeMy WebLinkAboutApp-Permit-ComplianceNo. �04{1p - -t9-d1 fc� / � � FEE e �_7� `VC/ XOMMONWEALTH OF M ASSACITUSETTS s�4q Board of Health, APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade (,.�( bandon- ZO Complete System ❑ Individual Components Location tcl N4 Owner's Name Map/Parcel# L� /2� J Address Lot# Telephone# . 72/ Installer's Name .4 d, r S ` " Designer's Name �.b.1L"C�.7 Address2 �/ se Z1/jC� j Address Telephone# Telephone# o 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) Ilf-11""d gpd Calculated design flow Design flow provided 04' -7 gPd Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No, Name of Soil Evaluator Date of Evaluation The undersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t o pl system in operation until a Certificate of Co fiance has been issued by the Board of Health. Signed Date Inspections No. COMMONWEALTH Of MASSACHUSETTS tSSACHLSETTS Board of Health, 1 , MA. /P� CERTIFICATE ©f COMPLIANCE � Description of Work: ❑ Individual Component(s) J2<omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,4<76andoned ( ) by: Z -e -r -e (A pof,3t at I C W � -��( has been installe '1 � 4rWa1e wi � provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. _/C.` ,�% , dated .Z- -'!C . Approved Design Flow (gpd) Installer .T�5-T-f A ba N) 15 ! Designer: %?rl>.c r T ! ; ,/ , /"/-. Inspector: Gk✓ `' Date: ,./ � /� ! Se The issuance of this permit shall not be construed as a guar a that the system will function as designed. c JT^ � Zi r� f`-_'r,�:-..<---1?Ei...Jn..:.C_o��0-91�-CJ^Ci-'a�Lic�c.�o�.CC-.'?_.)G^G�.(�CGva.C7.{;�c09 G�,00oo0oi;o 0_OCC_GocrU 00000 opo �-0o0oo(i0 or�r��coJCtl o -Cc }C1.G-d6 No. I�t3bti>G �tS�C f�Ea i?t pCo s l ; i FEE '55, 0 COMMONWEALTH LTH OF, MASSACHUSETTS e�'-� �Oq q Board of Health, A-72_ 046 1 M4= , MA. DISPOSAL SYSTEM" CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgradgj-,)--Abandon ( ) an individual sewage disposal system at 19 W'ROPai as described in the application for Disposal System Construction Permit No.�/_' , dated, X v //L Provided: Construction shall be c�mplete within thtZkf the date of this permit. All local conditions must be met. b i�ul 47 i' Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslaen. MA ~ Date .% > Board of Health � �' No.:BOHDGIS-0966 . Commonwealth of Massachusetts F� ass.00 Board of Health, Yarmouth, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to:Upgrade-Complete System Location: 19 WEST RD,WEST YARMOUTH, MA 02673 Owner: BRITA ERNEST D Map/Parcel#: 022.34 BRITA SUSAN F 420 PRINCESS ST ALEXANDRIA,VA 22314-2331 Phone: Septic System Installer Designer JEFF IADONISI DOWN CAPE ENGINEERING,INC. 371 SERVICE ROAD SANDWICH, MA 939 ROUTE 6A 02563 YARMOUTHPORT,MA 02675 Phone: (5081362-4541 Type of Building:Dwelling Lot Size:0.25 Acres Dwelling-No.of Bedrooms:4 Garbage Grinder: , Other Type of Building: No.of persoos: Showers: Other Fixtures: Plan Date:OS/28/2014 Number of S6eets: 1 Cafeteria• ' Tit1e:TITLE 5 SITE PLAN 19 WEST ROAD Revision Date: � Design Flow(min.required):440 gpd Calculated design flow:44 gpd Design flow provided:447 gpd ', Description of Soi1s:SEE PLAN Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:OS/28/2014 DA1vIEL GONSALVES,SE , DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-1500 GAL SEPTIC TANK,DBOX,32 QUICK 4 STANDARD INFILTRATORS W/OUT STONE FOR PROPOSED ADDITION � The undersigned agrees to install the above described Individual Sewage Disposal System in accordance wkh the provisions of TITLE 5 and further aarees not ta olace in ooeration until a Certificate of Comoliance has heen isaued bv the Board of Heakh. Signed Date � Inspections � 1 Commonwealth of Massachusetts � - Board of Health, Yarmouth, MA F� DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00 Permission is herby granted to; JEFF IADONISI CONSTRUCTION, 371 SERVICE ROAD,SANDWICH, MA 02563 To perform:Upgrade an individual sewage disposal system. Owner: BRITA ERNEST D BRITA SUSAN F 420 PRINCESS ST ALEXANDRIA,VA 22314-2331 Location: 19 WEST RD,WEST YARMOUTH,MA 02673 Disposal System Construction Permit No.: BOHDC-15-0966,Dated:February 06,2015 Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met. Conditions 1. BOH TO INSPECT SOIL REMOVAL 2. PLUMBING PERMIT REQUIRED 3.REPAIR-1 S00 GAL SEPTIC TANK, DBOX, 32 QUICK 4 STANDARD INFILTRATORS W/OUT STONE FOR PROPOSED ADDT170N r� � , � Bruce G. M h ,MPH, R.S., CHO/Amy .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. Commonwealth of Massachusetts Board of Health, Yarmouth, MA Fee CERTIFICATE OF COMPLIANCE 555.00 Description of Work:Complete System The undersigned hereby certify that the Sewage Disposal System; Upgraded ' by:JEFF IADONISI CONSTRUCTION at: 19 WEST 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-15-0966,dated 07/16/2015. Installer:JEFF IADONISI CONSTRUCTION Address:371 SERVICE ROAD SANDWICH,MA 02563 Inspector:AMY VON HONE,R.S. Designer:DOWN CAPE ENGINEERING,INC. Couditions 1.BOH TO INSPECT SOIL REMOVAL 2.PLUMBING PERMIT REQUIRED : 3.REPAIR- 1500 GAL SEPTIC TANK,DBOX,32 QUICK 4 STANDARD INFILTRATORS W/OUT STONE FOR PROPOSED ADDITION J(C/J� ` � f Bruce G. M h ,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. BO H_Disposal_Construction_CofC.rpt ; I ; ;