HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH LTH OF MASSACHUSETTS
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Board of Health, )�A R-P'l 0 t?Tl , MA.7A /(o ` �4� 2�
APPLICATION FOR DISPOSAL SYSTEM[ SON TRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeXAbandonO - Complete System ❑Individual Components
Location 1
Owner's Name
Map/Parcel# t 3 3
Address A—�Ae-%—C 1
Lot#
Telephone# ` 17 _ i
Installer's Name e a
Designer's Name
Address
Address '1 1 TWA e car
Telephone# _77 S
Telephone# ^ _
Type of Building
Dwelling - No. of Bedrooms�( A
Other - Type of Building
Lot Si z t-9. q sq. ft.
i Garbage grinder( )
of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date )0\\1 `J), Q015 Number of sheets 1- Revision Date
Title
Description of Soils)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton lace the system in operation until a Certificate of Com liance has been issued by the Board of Health.
Signed � �' �� , Date
Inspections
No.j�ovi DC FEE 65, 00
COMMONWEALT14 Of MASSACHUSETTS/-�C?�
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Board of Health,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Components)Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade Abandoned ( )
by: 1c:,
at
has been installed�in��ccor " ricwith the ro�isions of 310 CMR 15.00 (Title 5) and t pproved design plans/as-built plans relating to
application No. ��i !� - ated �� �� Approved Design Flow �(gpd)
Installer {'It L, M gym K)
Designer:!4WE(1-:1J(r Inspector:/� Date:
_ _The issuance of this permit shall not be construed as a guarautee that the system will function as designed.
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No. C -15 "gy8CAP `.'A f e COD S ePnC 5V C-5 FEE , Oa
COMMONWEALT14 Of MASSACHUSETTS CA* l 14(0
Board of Health, Y10 ern+ ,1vrA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at 1 cl _; k .1 ,'�,A(\
Disposal System Construction Permit No. �� ��� , dated �D
as described in the application for
Provided: Construction shall be completed within th-re sof tUe,6ate of phis permit. All local condi ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date . �G Bard o S /�
No.:BOHDGIS-2896
:
Commonwealth of Massachusetts Fee
ass.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
Location: 18 WILD HUNTER RD,YARMOUTH PORT, MA 02675 Owner:
OLSEN RICHARD F
Map/Parcel#: 132.34 PO BOX 82
YARMOUTH PORT,MA 02675
Phone:
Septic System Installer Designer
CAPE COD SEPTIC DOWN CAPE ENGINEERING,INC.
350 ROUTE 28 WEST YARMOUTH, MA 939 RTE 6A
02673 YARMOUTHPORT,MA 02675
Phone: 508-362-4541
Type of Building:Dwelling Lot Size: 12,632.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Ot6er Fixtures:
Plan Date:07l30/2015 Number of Sheets: 1 Cafeteria:
Tit1e:TITLE 5 SITE PLAN 18 WILD HUNTER ROAD Revision Date:
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:349 gpd
Description of Soils:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:07/28/2015
DANIEL GONSALVES,SE
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,16
HIGH CAPACITY INFILTRATORS W/OUT STONE:25'X 11.3'X 0.92'
� 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
Inspec6ons
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- Commonwealth of Massachusetts
- Board of Health, Yarmouth, MA Fee
' DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is hereby granted to;
CAPE COD SEPTIC SERVICES, 350 ROUTE 28,WEST YARMOUTH, MA 02673 '�
To perform: Upgrade an individual sewage disposal system.
Owner: OLSEN RICHARD F
PO BOX 82
YARMOUTH PORT,MA 02675
Location: 18 WILD HUNTER RD, YARMOUTH PORT,MA 02675
Disposal System Construction Permit No.: BOHDC-15-2896 ,Dated: August 10,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
COND/T/ONS:
1. SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK, DBOX, 16 HIGH CAPACITY
INFILTRATORS W/OUT STONE: 25'X 11.3'X 0.92'
2. MFC VARIANCE APPROVAL: a. SETBACK
,
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Bruce G. rph , MP , R.S., CHO/Amy E. 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.
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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:CAPE COD SEPTIC SERVICES
at: 18 WILD HLJNTER 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-15-2896,dated OS/13/2015.
Installer:CAPE COD SEPTIC SERVICES
Address:350 ROUTE 28 WEST YARMOUTH,MA Inspector:AMY VON HONE,R.S.
02673
Designer:DOWN CAPE ENGINEERING,INC.
C:�����
Bruce G. rphy, 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
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