HomeMy WebLinkAboutApp-Permit-ComplianceLS L,,j ` 9" — IS ---O 0 G-fJ 2--,3
/ C®MMO LTIT Of MASSAC14USETTS
/ Board of Health, YA2M o 1j"Ild , MA.
FEE53-O'0c4e 5-6-7
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(,/ ( Abandon - Complete System ❑ Individual Components
Location j
Owner's Name
Map/Parcel# ng3 Ir P Ile
Address 5^
Lot#
Telephone# J-25�
Installer's NameDesigner's
Name
Address 'I'' / 3'7
Address 97
Telephone#
Telephone#
ale
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) -300 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 of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS�� Lvr�
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 toplace the system in operati n until a Certificate of Compliance has been issued by the Board of Health.
Signed Date r/ f
Inspections
No 'v H Vc - 14-6C, 2.-( FEE 5 3 • �n
f4, C®MMONWEAI,TII Of MASSACHUSETTS
Board of Health, )L :,M 0 0-rtA , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: ( �f,4.,
at
has been insta led n acc r an e t provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application /No.+� ":� �� dated /�' .�� c��"7 �. yApproved Design Flow 'tel '" (gpd) !
Installer t ' ��� �" cX- ��6i ✓siJP�.�rA .�'1'fp' r 6�.J �' '
31V I'
The issuance of s permit s Inspector: `J f �u`t l� �Vr ' �' Date: � '
p all not be construed as a guarantee that the system will function as designed.
Designer: _
C. C
No. .�Q (I D t'9'6(0`�' V! 5 (`...� f/y L FEE J 5r G
C®MMON LTH OF MASSACHUSETTS --ff e'55 2
Board of Health, YAQAAl1
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereybygranted to; Construct( ) Repair( ) Upgrade( •,-) Abandon( ) an individual sewage disposal system
at ��rf ,/lff�--,wi 6�� �/,l.�1. as described in the application for
Disposal System Construction Permit No. /� —� ?`dated —�?�
Provided: Construction shall be co
m' p% �wit� n—lairs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date % / COard of Health
�� .
, No.: BOHDC-14-0626
' ` Commonwealth of Massachusetts F�
sss.�
Board of Health, Yarmouth, NIA.
APPLICATIt3N FdB DISPOSAL 5YSTEM CONSTRUCTIQN PERMIT
Appliaation for a Permit ko:Upgrade-Complete System
�I Locallon: 5 MORGAN RD,WEST YARMbUTH, MA 02673 Owner
Map/Parcel#: 023.48 Name:
MONROE PRTRfCiA E
11p SILVERLEAF LN WEST YARMQUTH, MA
02678
Phone.
Sepdc System Installer
Name:
CHASE&MERCHANT INC.
Address:
P.4.BQX 5 DENNISPORT,MA 02839
Phone:
Type of Building:Dwelling Lot Siu:0.1&Acres
Dwelling-No.of Bedrooms:3 Carbgge Grinder:
� Other Type of Building: No.otpersons: Showers: Cafeteria:
Ot6er Fi�ctures: �
PWn Dete: 10@8/2014 Number otSdeets: 1
Titk:SF,PTTC SYSTEM DESIGN 5 MORGAN ROAD Revision Dato:
Desiga Flow{min.reqnired):330 gpd Caleu(atsd desiSn tFow:330 gpd I)esige flow provided:330 gpd
Description of Sai1s:SEE PLAN
Soil Evaluator Form No.: Name otSoi!Evaluator: Date of Evaluaatan: 14101l20t4
STEPHEN HAAS,PE '
i
DESCR]PTIQN OF REPAIR5 OR ALTERATIONS: 1500 GAL SEPTIC TANK,DBOX,3-500 GAL PRECAS'1'CHAMBERS W/STpNE �
2'SIDES,4'ENDS:33'X 8.5'X 2'
• 7he underaigned agrees to inatall the above described Intlivitlual Sewaqe Disposal System in aocoMance wkh the provisiona ef
TiTLE 5 antl fuMrer aareas not M alace in oneration un8i a CartiFieate aF Cortwflam:e has been issuetl hv the Bosrd M Health.
, Signed Date
Inspections
�
�
�
� Commonwealth of Massachusetts
Board of Health, Yarmouth, MA. Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
i
Permission is herby granted to;JAY MERCHANT Address:P.O.BOX 5 �
DENNISPORT,MA 02639 j
To perform:Upgrade an individual sewage disposal system.
Owner. MONROE PATRICIA E
110 SILVERLEAF LN
WEST YARMOUTH,MA 02673
Location:5 MORGAN RD,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-140626,Dated:November 24,2014
Provided: Construction shall be completed within six mon[hs of the date of[his permit. All bcal conditions must be met.
Conditions
1. I500 GAL SEPTIC TANK, DBOX, 3-500 GAL PRECAST CHAMBERS W/STONE 2'SIDES, 4'
ENDS: 33'X 8.5'X 2'
2. MFC VAR7ANCE: I. SETBACKS
3. SLEEVE SEWER LINE AT WATER LINE CROSSING
�v
Bruce G. M h ,MPH, R.S.,CH0/Amy L.von Hone, R.S.,CHO II
Health Diredor/Assistant Health Director �
The issuance of t6is permit shall uot be construed as a guarantee that the system will fuoMion as designed. i
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