HomeMy WebLinkAboutApp-Permit-Compliance - EXPIRED2 r T /� f
No. D®0-� - 4 -CJI 10 13l--V� J15 " V 0 Z�G FEE
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/ k rZe-t—Board of Health, yo -r - r, -n. MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit t Construct epair( ) Upgrade (-,'/)Abandon () - Complete System ❑ Individual Components
Location G '� �� (
Owner's Name AA Iru.
Map/Parcel# Zg
Address 4 W M A -
Lot# %o K
Telephone#
Installer's Name M,Zk -X -T.��
Designer's Name
Address R LL MA 0Z6L,S
Address (3, MA C • 3 1
Telephone# ,,f-Z3-7-738dTelephone#
-4
Type of Building 7SI,
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures /Y A%
Design Flow (min. required) -1 4o
Plan: Date n -10 -ILI N
Title Pr --a Oka 4 aw,
Description of Soil(s) So -e- 411s1 We,
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS ORALTERATI(
The undersigned agrees to install the above c
further agrees to not to place the system in c
Signed ✓L17T'�-^
Inspections
No. of persons
Lot Size 11342- sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
sign flow provided=7 gpd
N
m Date 1• /A
of Evaluation
s
ice with the provisions of TITLE 5 and
.ied by the Board of Health.
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No.7t�Cr�7'O✓�� FEE
COMMONWEALTH OF MASSACHUSETTS "Suzq
Board of Health, AV:Ao t f + �T , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 3-60omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired ( ), Upgraded ( ), Abandoned ( )
by: i'Y;f .44
at LPJ LiC // 1.
toral-,e th e provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
has been installWr
application No. _L dated 0 U Approved Design Flow yy (gpd)
Installer iii 1�'Y�n✓( Tl-�
Designer: L..IVOWA-- Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. C� -Il( �C�I G 4�IrITUi� FEE
COMMONWF-ALT14 Of MASSACHUSETTS
Board of Health, YA,2.tkAd urN MA. � f
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct Repair( ) Upgrade ((Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within tkTer-M,'a? of
date of this per /n All local Eo--jrtitions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Bosto , MA Date Board of Health l_..
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No.:BOHDC-14-0516
' . Commonwealth of Massachusetts Fee
.-�sov-
Board of Health, Yarmouth, MA. ����.�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to:New Construction-Complete System �
Location: 6 JACQUELINE CIR,WEST YARMOUTH, MA 02673 Owner
Map/Parcel#: 029.39 Name:
WEBB ANDREW C
LINGOS TATIANA I 200 HINCKLEY RD
Phone:
Septic System Installer '
Name: '
EARTHH&STONE
Address:
218a QUEEN ANNE ROAD HARWICH,
MA 02645 '
Phone: '
Type of Building:Dwelling Lot Size:0.26 Acres
Dwelling-No.of Bedrooms:4 Garbage Grinder:
Other Type of Building: No.of persons: Showers: Cafeteria:
i
Ot6er Fixtures: 4
Plan Date: 10/10/2014 Number of Sheets• 1 �
Tit1e:PROPOSED SITE&SEWAGE DISPOSAL SYSTEM 6 JAQUELINE Revision Date: 11/14/2014
CIRCLE �
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Design Flow(min.required):440 gpd Calculated design flow:440 gpd Design flow provided:444 gpd j
F
Description of Soi1s:SEE PLAN
. Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:09/18/2014
LINDA PINTO,PE
, DESCRIPTION OF REPAIRS OR ALTERATIONS: 1500 GAL SEPTIC TANK,DBOX,25 ADS ARC 36HC iJNITS W/OUT STONE:25'X
14.4'X 0.89'
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 Heakh. ;
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Signed Date �
i
Inspections �
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� Commonwealth of Massachusetts
, Board of Health, Yarmouth, MA. Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $110.00
Permission is herby granted to; MICHAEL J. TAKACH Address: 218a QUEEN ANNE ROAD
HARWICH,MA 02645
To perform:New Construction an individual sewage disposal system.
Owner: WEBB ANDREW C
LINGOS TATIANA I
200 HINCKLEY RD
MILTON,MA 02186-2853
Location: 6 JACQUELINE CIR, WEST YARMOUTH, MA 02673
Disposal System Construction Permit No.: BOHDC-14-0516 ,Dated: November 24,2014
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions
1. ENGINEER TO INSPECT AND CERTIFY SEPTIC INSTALLATION PER PLAN NOTE '
2. 1 S00 GAL SEPTIC TANK, DBOX, 25 ADS ARC 36HC UNITS W/OUT STONE: 25'X 14.4'X 0.89'
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Bruce G. rp , MPH, R.S., C O/Amy L. von Hone, R.S., CHO
Health Director/Assistant Health Director '
he issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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