HomeMy WebLinkAboutApp-Permit-ComplianceNo. FJl1��"1J4 �` J 2-3�
COMMONWEALTH Of M ASSAC14USETTS
(� Board of Health, A-(ZMD ( , MA.
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APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMI1
FEE
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Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - Complete System ❑ Individual Components
Location r
Owner's Name ti `
Map/Parcel# w�
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address�
Address 5'
Telephone# Y,
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) 33 d gpd Calculated design flow -53 4Z� Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
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DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further,avzn to not to place the system in opera ' til a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No..604tbc.__4 5'2- 3," 1FEE
COMIM ON LTIT Of MASSACHUSETTS ® �/ ;•
BoardofHealth, AALMnin-14 MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Wcbmplete System
The undersigned hereby certify that the Sewage Disposal System;, Cons6ucted ( ), Repaired ( ), Upgraded (-*-A'6andoned. ( )
by
at
has been installed idld coldanc'! widf the pr6visions oM
application No. .r k.,dated
Installer 7--. Q'�
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Designer: spec
The issuance of this permit shall not be construed as a g
0 CMR 15.00 (Title 5) and the
Ap*'p�rooveeJd� Design Flow
design plans/as-built plans relating to
1.AWiGWL
that the system will function as designed.
No.
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COMMONWEALT14 Of MASSACHUSETTS 8 -
Board of Health, YP12-NIO UT -4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(—)'Abandon( ) an individual sewage disposal system ,
r
at as described in the application for
Disposal System Construction Permit No. dated
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Provided: Construction shall be completed within t f the date of this per it!ftll local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date �� " 6Board of Health �✓ 0
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No.:BOHDGIS-2309 �
Commonwealth of Massachusetts Fee
� $55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
Location: 443 WINSLOW GRAY RD, SOUTH YARMOUTH, MA Owner:
02664 LAMBROS VASILIKI(LIFE ES"1�
Map/Parcel#: 058.208 443 WINSLOW GRAY RD
SOUTH YARMOUTH,MA 02664
Phone: �
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Septic System Installer Designer ;
CHASE&MERCHANT PUNKHORN SERVICES I
P.O. BOX 5 DENNISPORT, MA 02639 P.O.BOX 483 !
Phone: SOUTH DENNIS,MA 02660 !
508-564-8379 �
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Type of Building:Dwelling Lot Size: 10,890.00 Acres I
Dwelling-No.of Bedrooms:3 Garbage Grioder:
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Other Type of Building: No.of persons; Showers:
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Ot6er Fixtures: j
E
Plan Date:04/03/2015 Number of Sheets: 1 f
Cafeteria:
Tit1e:PROPOSED SEPTIC DESIGN 443 WINSLOW GRAY ROAD Revision Date: i
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design tlow provided:351 gpd
Description of Soi1s:SEE PLAN ;
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Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:04/02/2015 �
ROBIN WILCOX,PLS
DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-PROPOSED I500 GAL SEPTIC TANK,DBOX,4 HIGH CAPACITY �
, INFILTRATORS W/STONE: 11'X 36'X 10" f
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�lace in oneration until a Certificate of Comoliance has been issued bv the Board of Health. f
` Signed Date �
f
Inspections (
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Commonwealth of Massachusetts
' Board of�Iealth, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
CHASE&MERCHANT INC., P.O. BOX 5, DENNISPORT, MA 02639 '
To perform:Upgrade an individual sewage disposal system. ;
Owner: LAMBROS VASILIKI(LIFE EST) ,
443 WINSLOW GRAY RD
SOUTH YARMOUTH,MA 02664
Location:443 WINSLOW GRAY RD,SOUTH YARMOUTH,MA 02664 '
Disposal System Construction Permit No.: BOHDC-15-2309,Dated:June 22,2015 '
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions '
1 REPAIR-PROPOSED 1 S00 GAL SEPTIC TANK, DBOX, 4 HIGH CAPACITY INFILTRATORS W/
STONE: 11'X 36'X 10".
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Bruce G. Mur y, PH, R.S.,CHO/Amy L.von Hone, R.S., CHO
ealth Director/Assistant Health Director
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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 $55.00
Description of Work:Complete System '
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:CHASE&MERCHANT INC.
at:443 WINSLOW GRAY RD, SOUTH YARMOUTH,MA 02664
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-15-2309,dated 11/13/2015.
Installer:CHASE&MERCHANT INC.
Address:P.O.BOX 5 DENNISPORT,MA 02639 Inspector:AMY VON HONE,R.S.
Designer:PUNKHORN SERVICES
Conditions '
1REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,4 HIGH CAPACITY INFILTRATORS
W/STONE: 11'X 36'X 10". '
Bruce . Mur y, 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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