HomeMy WebLinkAboutApp-Permit-ComplianceFEE � b-3 00
UUS S
COMMONWEALTH Of MASSAC
Am IVL4.
JAc Board of Health, A, CYC
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (� Abandon( ) - )0 Complete System 0 Individual Components
Location
Owner's Name
Map/Parcel# P
Address ;;L
Lot#
Telephone#
Installer's Name
Designer's Name
Address 0
Address
Telephone#Telephone#
6 OL
09.1 <1
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building —
Other Fixtures
Design Flow (min. required)Al
Plan: Date
Tide
Lot Size :3 . sq. ft.
Garbage grinder
No. of persons Showers Cafeteria
— gpd Calculated design flow 1��Q Design flow provided gpd
Number of sheets
Revision Date
Description of Soil(s) --4-z1- F A&Ze"'I
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
1111 P'' I I
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a t t to place the system in opera (!5ees o no until a Certificate of Compliance has been issued by the Board of Health.
Date
Signed -.1f Y A -'yy) ZA
L 10, 17
Inspections f 7
No. FEE :57 5' 06
COMM ON Of MASSACHUSETTS
Board of Health, Yaeffll) L)T74 z, 'A�I
CERTIFICATE Of COMPLIANCE
Description of Work: Q Individual Component(s) R omplete System
The
by:
at
has been install
application No.
Installer A
hereby certify that the Sewage Disposal System; Constructed Rep" 'Q (& Upgraded (t -)l' Abandoned
�-p i-- '9-ytf- ,
Xi ns of 310 CMR id design plans/as-built plans relating to
, t>ewrovisio 11K.00 (Title 5) and the` J
dated - 7-114 -. Approved Design Flow --Od) , /
I -- - 1, - --y � <7
Designer: 6 -Lfi-t� lnspectorI
1- cet. , -9 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. /-%0,v--/( -oloj FEE -Z)
COMMONWEALTH Of MASSACHUSETTS -2,q3
Board of Health, VM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrades( 0" Abandon( )an individual sewage disposal system
at -;:LF 7"1111051, X)41�X-40 as described in the application for
Disposal System Construction Permit No. dated F-1
ff
Provided: Construction shall be completed within th=.=ars of the date of this per it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Dates -Board of Health
No.: BOHDGt4-6t01.
Commonwealth af Massachusetts F�
$56.00 '
Board of Health, Yarmouth, MA.
APPLICATION FOR DISPOSAL SYSTEM CbNSTRUCTIUN PERMTT
Applicatiaq for a Permik to:Upgrade-Complete System
Location: 28 TASMANIA DR,YARMpUTH, MA p2675 Owner
Name:
MapiPareei#: 136.15 HU�SE, DONALD M
Address:
HULSE,MARILYN A 28 TASMANIA DR
Phorta:
Septic System Installer
Name:
CHASE&MERCHANT INC.
Address:
P.O. BOX 5 DENNISPORT, MA 02639
Phone:
5083982116 �
Type of Build'mg:Dwelling Lot Size:026 sq.ft.
�. Uwdtiog-Na.of Bedrooms:4 Garbage Grinder:
� Qt6er'CypeofBnitdiag: No.oYpersans: Showets: Cafeterffi:
Ofher Fixtures:
Ptaa DaM:06118/2414 Number of S6ests: t
1'ille:STTE P1.AN 28 TASMAIVIA DRIVE Revision Date:Q1/09/2414
Design Flow(min.rcquired):440 gpd Caloulated design ilow:44Q Design Flow provided:425 gpd
gpd
Descdption of Sotls:SES PLAN
5oil Evaluator Form No.: Name of Soil Evnluator. Date of Evaluation:06/I1/2014
BRIAN YERGATtAN,P.E.
DESCRIPTION pF REPAIRS OR ALTERAI'IONS: I SOp GAL SEP77C TANK
naox
4-500 GAL PRECAST CHAMBERS W/STONE: .
42'X8.83'X2'
The undersigned apress W install the above described Individual Sewage Disposal System in 8ecordance with the provisions
O(TIT�.E 5 atld fitRrie(a{afCEs itOt t0 D�2C8 71f oR@(d(i0�i1 un81 d CBIS�fiCaYB Qf(�.WliR��nGB h88 b89n i88t�d bY NiE g03ld O�1f8a�.
Signed Date
lnspec[ioos
Commanwealth of Massachusetts
Board of Health, Yarmauth, MA. Fee
DISPOSAL SYSTEM CONSTRUCTIUN PERMIT sss.00
Permission is herby granted to;JAY MERCHANT Address:P.O.BOX 5
DENNISPdRT,MA 02b39
To perform:Upgrade an individual sewage disposal syscem.
Owner: HULSE,DONALU M
HULSE,MARILYN A
28 TASMA27IA DR
YARMOUTHPORT,MA 02695-2156
Location:28 TASMANIA DR,YARMOUTH,MA 02695
Disposal System Construction Permit No.: BOHDC-140101 ,Dated:Auguet 07,2014
Provided:Construc[ion shall be enmpleted within six months of the date of this permit. All local conditions must be me%.
Can itions
Zone II Maximum 4 Bedrooms
MFC Varianees 1. Setbacks 2. Depth 3, 4%Leaoh Cupacizy Reductian
Install l S00 gal Septic Tank, DBox, 4-500 gal Precust Leach Chambers w/Stone:
42`x 8.83'x 2'
Walerdine to he relocatet�and sleeved.
&OH to inspect soil removal.
��'�� ��r�
Bruce G. urp y,MPH, R.S.,CHO!Amy L.von Hone,R.S.,CNO
Health pirector/Assistant Health Diredor
f •
The issuance of Shis permit shall not be conetrued as a guarantee that the system will functian as designed.