HomeMy WebLinkAboutApp-Permit-ComplianceL No.•
COMMONWEALT14 Of MASSAC14USETTS
Board of Health, 0 -rd , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(�bandon( ) - El Complete System �'Ix�dividual Components
Location
s�,I/
Owner's Name ;'
Map/Parcel#��
6
Address
Lot#
Telephone#('� S_
s�r
U CSS
e
Installer's Name
Designer's Names,
Address
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
OF REPAIRS ORALTERATIONS
030 /,cM:!� OaoA.
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
4145
gpd
The undersigned agrees t install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not I the tem /o gtie:t until a Certificate of Compliance has been issued by the Board of Health.
Signed 0`�-- 'J Date
Inspections
No. 604ADC _(5"'6917 FEE
COMMONWEALTH Of MASSACHUSETTS Zq4,5
Board of Health, yid i) -Mo 017"
CERTIFICATE OF COMPLIANCE
Description of Work: W161vidual Component(s) C3 Complete System
I
The undersid hereby certif that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded .(/Abandoned ( )
� r
by:
at R b 1i �r y17
has been installed accord nce Qt0h the provisions of 310 C 5.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /Y7 '/ dated 2 -6 ' . Approved Design Flow (gpd)
Installer t __
Designer: Inspector: ✓ Y Date: ' 12 -
The issuance of this permit shall not be construed as a guarante/e that the system will function as designed.
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No. C~1 --V�lG -7 FEE -.00
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COMMONWEALTH Of MASSACHUSETTS chi 2N 45
Board of Health, 0 VTIA , MA.
&141
YY DISPOSAL TEM CONSTRUCTION PERMIT
S SYSTEM
Permission is her .y granted to; Construct( ) Repair( ) Upgrade( -) Abandon ( ) an individual sewage disposal system
at / as described in the application for
Disposal System Construction Permit No. /�� , dated 2-
-7 7
Provided: Construction shall be completed within th @af, -of the date f this permit. All local conditions must be met.
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Form1�255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date � - '/ Board of Health c1._
No.:BOHDC-15-0997 �
Commonwealth of Massachusetts F�
ass.ao
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Application for a Permit to:Repairvminor-Individual Component(s)
Location: 135SULLIVANRD,WESTYARMOUTH, MA02673 Owner:
LUIZEN CHRISTINA . I
Map/Parcedl: 047.65 LUTZEN JOHN � '',
135 SULLNAN RD I
WEST YARMOiJTI-I,MA 02673 I
Phone: �
SepHc System Installer Designer lil
ELLIS BROTHERS
23 ENTERPRISE ROAD I
YARMOUTHPORT, MA 02675 �,
Phone: �
Type of Baildiog:Dwelling Lot Size:025 Acres I�I,
Dwelliog-No.of Bedrooms: Garbagt Grinder:
Other Type of Butlding: No.of persons: Showers:
Other Fiatures: �
Plan Date: Number otSheets: Gfeterta:
TiFle: Revision Date:
Design Fbw(min.rcquired): gpd Calculated desigo flow: gpd Desigo flow provided: gpd
Description of Soils:
Soil Evalaator Form No.: Name o[Soil Evaluator: Date of Evaluafion:
DESCRIP'I'ION OF REPAIRS OR ALTERAT[ONS:SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX PER INSPECTION
REPORT
The undenig�red agrees to i�fall the above described Individual Sewage Dbposal System In aeeordanee wXh She provislo�ro of � �'�,,
71TLE 5 and further aarees nM to olace In ooerotlon untll a CartlFleste M Comolianee has been issuetl bv the Board M HeaMh. I
Signed Date I
Inspections
i
� . II
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FBe
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
ELLIS BROTHERS CONSTRUCTION,23 ENTERPRISE ROAD,YARMOUTHPORT, MA 02675 �
To perform:Repair-minor an individual sewage disposal system. ',
Owner. LU1'ZEN CHRISTINA I
LUTZENJOHN ��
135 SULLNAN RD
WEST YARMOUTH,MA 02673 �
I
Location: 135 SULLIVAN RD,WEST YARMOUTH,MA 02673 I
Disposal System Construction Pernvt No.:BOHDC-15-0997,Dated:February 06,2015 I
Provided:Construction shall be completed within siac months of the date of this permit. All local conditions must be met. II
Conditions �
l. SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX PER INSPECTION REPORT i
i
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Bruce G.Murphy P , R.S.,CHO/Amy L.von Hone, R.S.,CHO i
He h Diredor/Assistant Health DireGor
The issuance of t6is permit shall not be construed as a guarantee that the system will FuoMion as desigaed.
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I
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Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
CERTIFICATE OF COMPLIANCE 555.00
Description of Work: Individual Component(s) ,
The undersigned hereby certify that the Sewage Disposal System; Repairvminor I
by:ELLIS BROTHERS CONSTRUCTION II
at: 135 SULLIVAN RD,WEST YARMOUTH,MA 02673
Has been installed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved �il
design plans or as-built plans relating to applicarion No.: BOHDC-15-0997,dated 02/12/2015. I
Installer.ELLIS BROTHERS CONSTRUCTION �I
Address23 ENTERPRISE ROAD YARMOUTHPORT, Inspector:AMI'VON HONE,R.S.
MA 02675
Designer.
Conditious
1.SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX PER CTION RT �
i
Brace G. Murp , , R.S.,CHO/Amy L.von Hone, R.S.,CHO
Health Director/Assistant Heaith Director
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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BOH_Disposal Construdion_CofC.rpt
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