HomeMy WebLinkAboutApp-Permit-ComplianceNo. e,() c - 1 J 1>6) � FEE i ` - ()0
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C®NINI®NWVALM Of MASSACHUSETTS -rQanc
Board of Health, )(49A 1 D UP+ , MA. T2 J 61- 0017 Z t
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct() Repair() Upgrade
,f,�Abandon() - ❑ Complete SystemA System.Individual Components
Location
Owner's Name
Map/Parcel#
Q�
Address
l
Lot#
Telephone#
50 � . 46 1
Installer's Name
f
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of
Other -Type of Building
Other Fixtures
Design Flow (min. Plan: Date d_1,equij1-
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersign es to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrtetotn to lace thein o ation until a Certificate of Co pliance has been issued by the Board of Health.
Signed Date
Inspections
No. Y^ ,• 'L_ OMMO LT14 Of MASSACHUSETTS FEE
Board of Health, YAA>f'1'l0UTW , MA.
_ CERTIFICATE Of COMPLIANCE � ''� � ���G� � J
Description of Work: -Individual Component -(s) 0 Complete System
The_undersigned h jeby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded f ,- Abandoned ( )
by: 1"
at
has been
Installer
tc o dat' with th ro�isions of 310 CMR 15.00 (Title 5) andnd t_ he roved design plans/as-built plans relating to
dated ' �..` r''Approved Design Flow (gpd)
Inspector:
Date: %a '(p
The issuance of this permit shall not be construed as a guaranto'that the system will function as designed.
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No. 04 C— S-- `t q 17 --- t" J� ���(G �rl ' i l al FEE
COMMONWEALTH Of MASSACHUSETTS -`786,
Permission is
at
Board of Health, ykg:1°1 Q OTR- , MA.
DISPOSAL SYSTEM ST CONSTRUCTION PERMIT
(granted to; Construct( ) Repair( )
Anj 1--/) f"`, n._e__�
Upgrade Abandon( ) an individual sewage disposal system
_ as described in the application for
Disposal System Construction Permit No. Z; dated
Provided: Construction shall be completed within th>+s-of tFi date of this 7perit l local Gond' ;'o. s must be met.
01� S
.� �1- j
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Date card of H
�^ ealth
No.:BOHDGIS-4482
� 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: 16 WIDGEON LN,WEST YARMOUTH, MA 02673 Owner:
COOK JEFFREY A
Map/Parcel#: 058.305 COOK LINDA
98 DRIFTWOOD LN
SOUTH YARMOUTH,MA 02664
Phone:
Septic System Installer Designer
B&B EXCAVATION DOWN CAPE ENGINEERING,INC.
14 TEABERRY LANE FORESTDALE, 939 ROUTE 6A
MA 02644 YARMOUTHPORT,MA 02675
Phone: 508-362-4541
Type of Building:Dwelling Lot Size: 10,454.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Ot6er Fixtures:
Plan Date:08/21/2015 Number of S6eets: 1 I
Cafeteria:
Tit1e:TITT,E 5 SITE PLAN 16 WIDGEON LANE Revision Date:
Design Flow(min.required):220 gpd Calculated design flow:220 gpd Design tiow provided:349 gpd ,
Descripfion of Soi1s:SEE PLAN
i
Soii Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:08/20/2015 �
DATtIEL GONSALVES,SE
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,2-500
GAL PRECAST 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 Health.
Signed Date �
Inspections
i
,
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
B&B EXCAVATION, 14 TEABERRY LANE, FORESTDALE, MA 02644
To perform:Upgrade an individual sewage disposal system.
Owner: COOK JEFFREY A
COOK LINDA
98 DRIFTWOOD LN
SOUTH YARMOUTH,MA 02664
Location: 16 WIDGEON LN,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-4482,Dated:September 29,2015
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-EXISTING 1000 GAL SEPTIC TANK, DBOX,2-500 GAL PRECAST
CHAMBERS W/4'STONE:25'X 12.83'X 2'
�C.J�I
Bruce G. M hy, 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 t6at the system will function as designed.
i
. �
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
CERTIFICATE OF COMPLIANCE 555.00
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:B&B EXCAVATION
at: 16 WIDGEON 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-15-4482,dated 10/26/2015.
Installer:B&B EXCAVATION
Address:l4 TEABERRY LANE FORESTDALE,MA Inspector:AMY VON HONE,R.S.
02644
Designer:DOWN CAPE ENGINEERING,INC.
� '
Bruce G. Mu ,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.
BO H_Disposal_Construction_CofC.rpt :
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