HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE J. OjI
COMMON LTH OF MA -SS C114USETTS Board of Health, Yarmouth _,MA.
1�711( APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair(& Upgrade(j Abandon( ) - � Complete System ❑ Individual Components
Location 129 Blue Rock Road
Owner's Name
James Langen
Map/Parcel*] 1
Address 33
Broad St. Ste 1100, Boston
Lot# 2
Telephone#
61 7- 9 7 3- 0 5 71
Installer's Name b D2-n, 0-M COA)SVOCVJN 1AIC
Designer's Name i'ell ns Civil Eng- Group, Inc.
Address 6, e?ox 7,o 4
Address
225 SO. Main 3L, W. tiridgewater
Telephone# Sb8— %/' 9.3'75
Telephone#
Type of Building Residential house Lot Size 0.35 Ares±sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow 330 Design flow provided 4 9 0 gpd
Plait: Date 8-1 —1 7 Number of sheets 1 Revision Date
Title Plan and Details Subsurface Sewage Disposal System Upgrade
Description ofSoil (s) 0-1 6" Fill/A; 1 6-38" Sandy Loam; 38-1 50" MED. Sand
Soil Evaluator Form No. 11 Name of Soil Evaluator G . R . Co l l i nS Date of Evaluation 6 — 2 2 —1 7
DESCRIPTION OF REPAIRS OR ALTERATIONS Install new 1,500 Gal., 2—Compartment septic
tank.Distribution box, and 14.2' x 28.0' Leaching Bed with 5 rows
of 7 Quick
4 Plus Standard Low Profile Chambers
The undersign
agree o ' t the above described Individual Sewage Disposal System-1 h accordance with
5 and
further ee
Signed
a system m opera til a Certificate of Co pli ce has been issued by
Date �8 010 b
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Inspections
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COMMONWEALTH OF M�
FEES. �(
ACHUSETTS 1'*JeeO ' 3z�s
Board of Health, Yarmouth , MA. rl lr`r'h'�'°'
CERTIFICATE Of COMPLIANCE FeilY,14
Description of Work: ❑ Individual Component(s) P Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ($), Upgraded N, Abandoned ( )
by; �tavl.g-Iti �oNsl6 t� t I`1 R
at 12,9 e> WC- QDcx- r
has been installed in accordance with the provisions of.310 CMR 15.00 (Title 5) and th Approved design plans/as-built plans relating to
application No l `] - 17S dated - ' f Y Approved Design Flow } V d) _ ; ¢ �+!
Installer �`�b �i�(_C:3 fc° y,,�";; �' •��`�
Designer: COLO 05 Ct11 I CT.2L%. !� Inspector: Date:
The issuance of this permit, shall not be construed as a guarantee that the system will function as designed
No.���G" �V FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, Yar, mouth MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(b Upgrade(j) Abandon( ) an indhidual sewage disposal system
at / Zi Al Vt- le0 C;%- 12()41) as described in the application for
Disposal System Construction Permit No. I e dated . —` J1 -
Provided: Construction shall be completed within three -years of the date of this emit. All local Q nditions must be met.
For`m1255Rev5l96 AMSulko.chatlestavnMDBoard o Health
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