HomeMy WebLinkAboutApp-Permit-Compliance�® o. &8 K7(I4-6q(( THE COMMONWEALTH OF MASSACHUSETTS FEE �®
BOARD OF HEALTH
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair (P(4 Upgrade ( ) Abandon ( ) - []Complete System ❑ Individual Components
4/aC� Gri. qS/ort�s� rcr/
Map/Parcel #
Lot #
0 V` Ins Iler's Narde
J Address
JSDS - ?71-4-- 1-F91?0
Telephone #
V
u'� Type of Building: % / iz. % ✓% f�%?;s'
Dwelling - No. of Bedrooms 3
Other - Type of Building No. of persons
Other fixtures
wner's Name
Address
Telephone #
Designer's Name
Address
Telephone #
Lot Size Sq. feet
Garbage Grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow gpd Design flow provided gpd
Plan: Date Number of sheets Revision Date
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
K
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date /O Z,-- Z, -
Inspections
InspectionsGc-
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FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No 56H PC � �r / ..,,THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH 4� �)�,•%° C rL- flo
CERTIFICATE OF COMPLIANCE
Description of WorIndividual Component(s) ❑Complete System
The undersigned hereby certify that the, Sewage Disposal System; Constructed( ),Repaired (b, Upgraded( ), A and ed (-"')�
b .� / �,/ df, � ��
y r 6L `) b )d4 STS / r1 /
at roc'' G;- r-
has been installed in accorda ce ith the prc
plans relating to application Ia/
�-
of 310 CMR 15.0 (Title 5) and the approved design plans/as-built
1'0 -:j -'/rApproved Design Flow — (gpd)
Installer
Designer: Inspector Date,
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. ICI- C416THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH L L/
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair (Ot) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at as described
in the application for Disposal System Construction Permit No. i'7rrfl,L /q - (��/� , dated /b
/Z - >
Provided: Construction shall be completed within three years of the ate of this permit. All -lo al conditions must be met.
i
Date /0 �� Board of Health f
FORM 2 - DSCP DEP APPROVED FORM 5/96 F
FORM 1255 (REV 5/96) Hi HOBBS&WARREN TM PUBLISHERS- BOSTON
i F �
� . ,
�. No.:BOHDC-14-6416
Commonwealth af Massachusetts F�
$55.00
Board af Health, Yarmoath, MA.
; APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI4N PERMIT
iApplication for a Permit to:Repair-minor-Individaal Camponent(s}
i LocaHao:408 WINSLOW�RAY RD,WEST YARMOUTH,MA 8wner
� R�ap�Parce!#:058_3'10 �UIER DUSTIN T
Address:
ROGOWSKI REBECCA PO 64X 194
Phone:
Sepdc System Instailer
i Name:
� NEIGHBORHOOD WASTE WATER
SERVICES
ES�IfvBB!!TE 28 WEST YARMOUTH,
MA 02673
Phone:
Type of Buiidiog:Dwelling Lot Siu:02b sq.ft.
6welling-No.of Btdroams: Garbage Grinder:
Qt6er Type of Building: Nu.of persons: Showers: Cateteria:
Ot6er Futures:
Piao Date: Number of SAeets:
TiNe: Revisioa Date:
Design FMw(mioxequired)t gpd Calcuiattd desi�n tiaw: gpd D¢sign fiow provided: $pd
Doscription of Soils:
Soil Evaluator Form No.: Namo of 5oi1 Evaluator: Date of Evaluation:
DESCRiPTIpN OF REPAIRS OR ALTERATIONS:REPAIR EXISTING LEAKING t000 GAL SEPT[C TANK
The unde�sig�tl agreea to inataii the abova tlescribed lndividuai Sewa�Disposai System in aceardanee with the prov�ions
of TITLE 5 and furGler agrees nM W qlaee In operotlon untll a CertlFleate M Compllance has been issued by!he Board M Heallh.
Signed Date
Inspec[ions
, Y . �
� , .
Commanwealth of Massachusetts
Board af Health, Yarmauth, MA. F�
� DISPOSAL SYSTEM CONSTRUCTION PERMIT S5S.08
Permission is herby granted to;FAUL MARTIN Address:350 ROUTE 28
� WEST YARMOUTH,MA 02673 �
iTo perform: Repair-minor an individual sewage disposal system.
. C?wner: AiGUIF,R DUSTIN T
ROGOWSKIREBECCA
PQ BOX 19&
SOUTN YAk.MOUTH,MA 02664-0194
i
Locatian:408 WINSSAW GRAY RD,WEST YARMOUTH,MA Q2673
� Disposal System Construction Permit No.: BOHDC-14Q416,Dated:4ctober 03,2014
� Provided:Construction shall be completied within six months of tha date of this parmit. All loaal conditions must be met.
, onditiana
1. Repair existing 1Q(t0 gat Septic Tank Leak per inspection
C�l
Bruce G. rph ,MPM,R.S.,CH4 t Amy L.wn Ho�e, R.S.,CH6
, Health Director/Assistant Health diredar
T6e issuance of this permii shall aot be construed as a guarantee that the system will function as designed.
Commonwealth of Massachusetts
; Board af Health, Yarmouth, MA. F�
CERTIFICATE OF CClMPLIANCE ��0°
� Description of Work: Individuai Camponent(s}
� 772e undersignad hereby oertify that the Sewage Dispasa] System; Repair-minor
, by:NEIGHBORHOOD WASTE WATER SERVICES
II at:4�8 WINSLOW GRAY RD,WEST YARMOUTH,MA 02673
flas baen installed in accoxdance with the provisions of 310 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDC-14-0416,dated 10/p8/2014.
' Installer:NEIGHBORHOqD WASTE WATER SERVICES
� Address356 ROUTE 2$WES`T YARRidUTH,MA Inspector:AMY VON HONE,R.S.
02673
i Designer:
Cand9tians
' 1.Reuair existinQ 1000 eal Seotic Tank Leak oer inspectioa
' �i�r�
' Bruce G.Murphy, PH, R.S., CHO/Amy L.von Hone, R.S., CHO
Health Director!Assistant Heafth DirecCor
IThe issuance oYthis permit shall not be construetl as a gus�rantee Yhat ihe system witl funetioo as deslgned.
I
BOH_Dispasal_Cqnstruction_CofC.rpt �