HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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COMMONWEALTH LTH ®F MASSACHUSETTS
Board of Health, AZmoorw , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon()--41'Complete System O Individual Components
Location ��,/�
Owner's Name ,
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
Designer's Name SAO
Address
Address
Telephone#
Telephone# O _ Q
Type of Building L -
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size
sq. ft.
— Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) �U gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name S-6 6( Evaluator
J
DESCRIPTION OF REPAIRS OR ALTERATIONS 6 6(
Date of Evaluation
U
The undersigned avr4s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre Ito pla a operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
..,..-C.,. i.
No.. 1�, / FEE J 3 !d
COMNIONWEAI.TII OF MASSAC14USETTS
Board of Health, YP,OVT}j , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned herebycertifythat the Sewage Disposal System; Constructed (, _), Repaired ( )> Upgraded-tl, Abandoned ( )
at
has been instalyd m accorda ce wi a ro�zsi ns of 3 CMR 15.00 (Title 5) an the a proved design plans/as-built plans relating to
application No... !'`� dated ^ ' �! Approved Design Flc,4 (gpd)
Installer /°��t%G�✓ �f t` :�r'i�� l re r I --r
Designer: r��s'v'U -7 Inspector:' 1 Date:
The issuance of this permit shall,not be construed as a guarantee that the system will function as designed.
o 0 o: :, 0 _'dtJ o 0 0 0: Do c c, tSo O tio.culo co o o -ac. G: o0 0g-o-9-esfl�%ae
No. �� 31% % // FEE U L�
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, yA2M D JTZ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;/Construct( ) Repair( ) Upgrade(.}' bandon( ) an individual sewage disposal system
at 0✓��� /�} UCS' �t'� as described in the application for
Disposal System Construction Permit No. �-�� , dated
Provided: Construction shall be completed within tlT-ee ye 'of the date of this per(1,4
l local conditions must be met.
<� 0%C i
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ���� �Boar�of Health
/s
I
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No.:BOHDC-15-4474
� Commonwealth of Massachusetts Fee
555.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System '
Location: 22 WILD HUNTER RD,YARMOUTH PORT, MA 02675 Owner: '
BOWSER BRIAN L
Map/Parcel#: 132.33 BOWSER SANDRA L
22 WILD HUNTER RD
YARMOUTH PORT,MA 02675-1248 �
Phone:
Septic System Installer Designer
MIRANDA'S EAS SURVEY,INC.
476 MAIN STREET HARWICH, MA P.O.BOX 1729 '
02645 SANDWICH,MA 02563
Phone: '
508-888-3619 �
Type of Building:Dwelling Lot Size: 12,632.00 Acres �
Dwelling-No.of Bedrooms:4 Garbage Grinder:
Other Type of Building: No.of persons: 56owers: ,
Other Fixtures: '
'
Plan Date:06/26/2015 Number of Sheets:2 '
Cafeteria: '
Tit1e:SITE&SEWAGE REPAIR PLAN 22 WILD HUNT'ER ROAD Revision Date: �
Design Flow(min.required):440 gpd Calculated design flow:440 gpd Design flow provided:447 gpd i
�
Description of Soi1s:SEE PLAN �
i
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:06/17/2015 ;
EDWARD STONE,PLS �
' DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,32 i
INFILTRATOR QUICK 4 STANDARD UNITS W/OUT STONE:32'X 11.33'X 8"
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 Comnliance has been issued bv the Board of Health. ;
i
Signed Date
�
�
Inspections �
i
�
�
�
�
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�
i
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Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
Permission is herby granted to;
MIRANDA'S EXCAVATING,476 MAIN STREET, HARWICH, MA 02645 '
To perform:Upgrade an individual sewage disposal system.
Owner: BOWSER BRIAN L
BOWSER SANDRA L '
22 WILD HiJNTER RD
YARMOUTH PORT,MA 02675-1248
Location:22 WILD HIJNTER RD,YARMOUTH PORT,MA 02675 '
Disposal System Construction Permit No.: BOHDGIS-4474,Dated: September 23,2015
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-PROPOSED 1500 GAL SEPTIC TANK, DBOX,32 INFILTRATOR QUICK 4
STANDARD UNITS W/OUT STONE:32'X 11.33'X 8"
2. BOH TO INSPECT SOIL REMOVAL f
�
i
i
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 wilt function as designed. '.
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
CERTIFICATE OF COMPLIANCE $55.00
Description of Wark:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:MIRANDA'S EXCAVATING
at:22 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-15-4474,dated 11/13/2015.
Installer:MIRANDA'S EXCAVATING
Address:4'76 MAIN STREET HARWICH,MA 02645 Inspector:BRUCE MURPHY,R.S.
Designer:EAS SURVEY,INC.
U�f
Bruce G. M ph , MPH, R.S., CHO/Amy L.von Hone, R.S.,CHO
� Health Director/Assistant Health Director
1
The issuance of this permit shall not be construed as a gua�ntee that the system will function as designed.
BOH_Disposal_Construction_CofC.rpt