HomeMy WebLinkAboutApp-Permit-ComplianceNo. & gDC -4 ' v ! k - 1:5- - OOa / sG FEE .UA
e, /I G, COMMONWEALTH Of MASSACHUSETTS &*Zges",
Board of Health, ,Y/fh01i� , MA.
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//SAPPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
lication for a Permit to Construct( ) Repair( ) Upgrade( Abandon() - [,Complete System ❑ Individual Components
Location
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Owner's Name ,fee,.
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Map/Parcel#
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Address
Lot#
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Telephone#
Installer's Name
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Designer's Name
Address
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Address ,Q3
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Telephone#
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Telephone# S093AK
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Type of Building H -r .h O rn � ,. ) Lot Size 6.1U3_ sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) ® gpd Calculated 9design flow-? 3 d Design flow provided , gpd
Plan: Date 7 las Number of sheets / Revision Date Al
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS I A J41) IS06 Qui T. P l ax S id..S'.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to a the system in operation until a Certificate of Co phi ce has been issued by the Board of Health.
Signed Date _ �/ 6�
Inspections e1L
/9 z
COMMONWEALTH Of MASSACHUSETTS o,� �p cit -4
Board of Health, )A-dzM0Q-FA , MA. l'V�
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ?QF-omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(t'j, Abandoned ( )
by: c�r�-, rte,
at �7'�
has been installed inlac corAanc& with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.�i,, ,1 )l , -t ) dated S "' Z 4 '/ Approved Design Flow / (gpd)
Installer
Designer: 44Inspector: 16 i �j/ �� - Date:
The issuance of this permit shall not be construed as a guarant a that the system will function as designed.
No. 1 ` C - q l� - �} C . � .. FEE Ufii
C®MMONWEALTII Of MASSACHUSETTS
Board of Health, Vlt�M6lrT-}{ , MA.
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. /4 dated (7 i 1r
Provided: Construction shall be completed within-da-r-ee-ye-srsG0 t e date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date L -'/-� 6 /Board of Health
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:RIKER LAND CONSTRUCTION
at: 53 NAUSET RD,WEST YARMOUTH,MA 02673
Has been installed in accardance with the provisions of 310 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDC-14-0255,dated 10/06/2014.
Installer:RIKER LAND CONSTRUCTION
Address:P.O.BOX 726 SOUTH YARMOUTH,MA Inspector:AMY VON HONE,R.S.
02664
Designer: SWEETSER ENGINEERING
Conditions
1.Board of Health Agent to Inspect Soil Removal
2. 1500 gal Septic Tank,DBox,4 High Capacity Infiltrators w/Stone in n "L" Trenc Cofiguration
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Bruce G. Murphy, H 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.
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