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Home My WebLink AboutApp-Permit-ComplianceCOMM0 du Of NIXSSAC USETTS Board of Health, Z' �i'�Y m u -n , MA. FEE � i 5.0 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repairy Upgrade( ) Abandon( ) - 0 Complete System XIndividual Components Location ` A Ck r - Owner's Name Map/Parcel# / Address Lot# Telephone# Installer's Name C)v �d , Designer's Name Address r LI �.� } ddress Telephone# ' L Telephone# Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soils) gpd Calculated design flow Number of sheets Lot Size No. of persons sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation L3rA]arl.e'r ,.e DESCRIPTION OF REPAIRS OR ALTERATIONS f P til r4, �/in 'r IJ -L7 Z eeLb S GAn �4 0 Py C- 14, Pe 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 place the em in oppee�rafon until a Certificate of Compliance has been issued by the Board of Health. Signed _/ �/ " !! Date! Wi 9 -- Inspections - .. No. i_3DPZ/ "",$4 A; ls� . �EE — , 4D COMMONWEALTH Of MASSACHUSET � Description of Work: The undersigned her by: at Board of Health, MA. CERTIFICATE Of COMPLIANCE [)individual Component(s) C] Complete System ry certify' at the Sewage Disposal System; Constructed ( ), Repaired (�f,'Up�ded ( ), Abandoned "( ) .ii (�ve) /, T has been installed in accor'daance// the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. � V 144 ted l�� . Approved Design Flow �" (gpd) Installer YZ Designer: •"r- /Inspector: Date: 7.1 /G The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No.l r �� AL% FEE COMMONWEALTH Of MASSACHUSETTSp( /-�/, Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby ranted to; Construct( ) Repairo j Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No�1-14 1 (4�ed F-2_2 P f Provided: Construction shall be completed thin �`ef�j, �date of this p / It. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Dat9P �� Board of Health No.:BOHDGl4-0165 Commonwealth of Massachusetts Fee 3ss.00 Board of Health, Yarmouth, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Applicatioo for a Permit to:Repair-minor-Individual Component(s) Location: 11 YACHTAVE,WESTYARMOUTH, MA02673 Owner Map/Parcel#: 022.139 Name: SULLIVAN EVELYN E Address: 11 MYRTLE ST BELMONT, MA 02178-3004 Phone: CONTRACTOR Name: ROBERT B. OUR, CO., INC. Address: 24 GREAT WESTERN ROAD HARWICH, MA 02645 Phone: 5084320530 Type of Building:Dwelling Lot Size:025 sq.ft. Dwelliog-No.of Bedrooms:3 Garbage Grinder: Other Type of Building: No.of persons: Showers: Cafeteria: Other Fixtures: Plan Dah: � Number of Sheets: TiHe: Revision Date: Design Flow(min.required):330 gpd Calculahd design tlow:330 Design tlow provided: gpd gpd DescripAoo of Soils: � Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: • DESCRIPTION OF REPAIRS OR ALTERATIONS:REPLACE ORANGEBURG PIPE BETWEEN FOUNDATION AND EXISTING LEACH PIT The underslgnetl agreea to insfall the above descrl6ed Individual Sewage Dlsposal System in accordance with the provisions � oT TITLE b and fuRher aArees not to plaee in oceratlon until a Cert�cate of Complianee has been issued by the Boartl of Heatth. Signed Date Inspec[ions j Commonwealth of Massachusetts � Board of Health, Yarmouth, MA. F� ' s�.00 ; DISPOSAL SYSTEM CONSTRUCTION PERMIT i I � Permission is herby granted to;CHRIS OUR Address:24 GREAT WESTERN ROAD HARWICH,MA 02645 To perform:Repair-minor an individua7 sewage disposal system. Owner: SULLNANEVELYNE � 11 MYRTLE ST BELMONT,MA 021783004 Location: 11 YACHT AVE, WEST YARMOUTH,MA 02673 Disposal System Construction Permit No.: BOHDG140165,Dated: August 26,2014 Provided: Construction shall be completed wi[hin six months of[he da[e of this permi[. All local conditions must be met. Conditions Replace orangeburg pipe behveen foundation and existing leach pit. Bruce G. rp , M 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.