HomeMy WebLinkAboutApp-Permit-ComplianceNo. OVNDG✓S �
�'o1V LD 11Z —It0 —W� c55 (� FEE �� -V�
C®Nl MONWEA
LTII Of MASSAC14US TTS c� ��
Board of Health, �A-2-moo-)A , MA-�,�,x � A 6
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (,�Abandon( ) - ❑ Complete Syste�vidual Components
Location
Owner's Name
Map/Parcel#
jr'L{' ,Z �p
Address -75 f o . NaL
Lot#
Telephone# � Gj Z
Installer's NameDesigner's
Namei a
Address 14 � W. FOAkWME
AddressJO(MoofK AAA
Telephone# b
# C
z ���
Type of Building � � l r� 5n Le � 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) gpd Calculated design flow Design flow provided 414R gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS hM --✓
The unde5gned grees toinstall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthero place the t m in o e tion until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. l: FEE S
COMMONWEALTH OF �SSACHUSETTS C� Z�Z�
Board of Health, 7 %a MO U -M MA. K\,(
CERTIFICATE Of COMPLIANCE
Description of Work: .4alln-dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (-�-Abandoned ( )
by:
has been instal ed in acc rd cu/e wiW61le provisions of 310 CMR 15.00 (Title 5) ani t�h pproved design plans/as-built plans relating to
application No. S// �� (O, dated 7��� �� /� . Approved Design Flow f
Installer j Y ''°FJ �1 LT v ! t-�::Of"
Designer: r-LA!•11R1L7ti1 "hV` Inspector: rJ Date:
7L y
The issuance of this permit shall not be construed as a guarana that the system will function as designed.
No. 7® kA r- - 15 -1 (c, (7 ,� E is CAV 4D O N FEE
/S �9
COMMONWEALTH OF MASSAC14USETTS �'41L- z (4 �
Board of Health, y (—m O OTIy
DISE®SAI. SYSTEM ST CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade —r- Abandon( ) an individual sewage disposal system
at / `J n \N `/C 1( m /) () A r\ C U i 1) �( t l � nr)L C-�XI as described in the application for
Disposal System Construction Permit No. / S %1� , dated 7—
Provided: Construction shall be completed within three-rears�/4,t� the date this perit. All local conditions must be met.
(
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health C
No.:BOHDC-15-1166
' Commonwealth of Massachusetts Fee
ass.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Component(s)
Location: 755 WEST YARMOUTH RD,YARMOUTH PORT, MA Owner:
02675 DAUBERT HOLLY J
Map/Parcel#: 095.26 755 WEST YARMOUTH RD
YARMOUTH PORT,MA 02675
Phone:
Septic System Installer Designer
B&B EXCAVATION FLAHERTY ENVIRONMENTAL SERVICES
14 TEABERRY LANE FORESTDALE, P.O.BOX 81
MA 02644 YARMOUTHPORT,MA 02675
Phone: 774-994-1166
Type of Building:Dwelling Lot Size:24,394.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Ot6er Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:07/16/2015 Number of Sheets:2
Cafeteria:
Tit1e:SITE AND SEWAGE PLAN 755 WEST YARMOUTH ROAD Revision Date:
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:348 gpd
Description of Soi1s:SEE PLAN
• Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:07/16/2015
DAVID FLAHERTY,R.S.
i
; DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTTC TANK,DBOX,2-500
GAL PRECAST H-20 CHAMBERS W/4'STONE:25'X 12.83'X 2'
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 HeaRh.
Signed Date
Inspections '
; Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $ss.00
Permission is herby granted to;
B&B EXCAVATION, 14 TEABERRY LANE, FORESTDALE,MA 02644
To perform:Upgrade an individual sewage disposal system.
Owner: DAUBERT HOLLY J
755 WEST YARMOUTH RD
YARMOUTH PORT,MA 02675
Location:755 WEST YARMOUTH RD,YARMOUTH PORT,MA 02675
Disposal System Construction Permit No.: BOHDC-15-1166,Dated:July 21,2015
Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met.
V�
Bruce G. Mu hy, PH, R.S.,CHO/Amy L.von Hone, R.S.,CHO
eaith 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 ass.00
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:B&B EXCAVATION
at:755 WEST YARMOUTH RD,YARMOUTH PORT,MA 02675
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-15-1166,dated 07/24/2015.
Installer:B&B EXCAVATION
Address:l4 TEABERRY LANE FORESTDALE,MA Inspector:AMY VON HONE,R.S.
02644 '
Designer:FLAHERTY ENVIRONMENTAL SERVICES
'j �C�Ce/ � �
Bruce G. M phy, PH, 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
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