HomeMy WebLinkAboutApp-Permit-ComplianceNo.' POt-4DCW11248 JE3 41) -LI // 4 T�j k FEE 551 00
/5--69 C® ®N LTH Of MASSACHUSETTS
Board of Health, )IA -9 -MO 0- } , MA.
APPLICATION FOR DISPOSAL SYSTEM C®NSTRUCTI®N PERMIT
Application for a Permit to Construct( ) RepairM/UpgradeO Abandon( - ❑ Complete System ❑ Individual Components
Location q SAWerZFWK
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Owner's Name /Wit G4V_r
Map/Parcel# AL>Address
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Lot#
Lot#
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Telephone#
Installer's Name�T
Designer's Name
Address 2-16 ,6�n Pd'1
Address
Telephone#
t7 7' C-7-15
Telephone#
Type of Building Ae_e> i ek—fl. 1'1 r, I Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 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 W 14C -P_ g G * ai P1 l r� � `rilqtk�,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furtherees to n t top ce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed &atrcv. -Cr-Z. Date /' ZY
Inspections
No. b DC-4S-I�SB FEE t 5S, 0
COMMONWEALTH Of MASSACHUSETTS ck400�� �
Board of Health, YAa4n111V , MA,
CERTIFICATE Of C®MELIA CE
Description of Work: D Individual Component(s) El Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned
1�( )
by: 09P -- 8, OC"1" ec . L n,! .
at Rrt��ok 4J
has bee�ristalleli' in acc�dda4lce wit t e$r stops of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicatio No. dated "/ C. Approved Design Flow — — (gpd)
Installer kD&rT .S , Vur- ln. Z� CN{L(S-,,bpwc_� W . 0 UC_
Designer: Inspector: Date: _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
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FEE f CJS - 00
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Board of Health, TAamnimi , MA. 'Z ( 0 r-,
DISPOSAL SYSTEM CONSTRUCTION,.,PERMIT V�
Permission is hereby granted to; Construct( ) Repair (0 Upgrade ( ) Abandon( ) an individual sewage disposal system
at rrV K as described in the application for
Disposal System Construction Permit No. - �� , dated
Provided: Construction shall be completed wlthin ireyars of the date o is permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Date 4/ a'`1 l( Board of Health
,
No.:BOHDC-15-1858
Commonwealth of Massachusetts F�
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Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to: Repairvminor-Individual Component(s) ,
Location: 9 BEAVER BROOK RD,WEST YARMOUTH, MA 02673 Owoer:
NESSLER NANCIE
Map/Parcel#: 058.354 C/O BRYAN BOWER
2624 N SAUNDERS LAKE DR '
MINNETRISTA,MN 55364
Phone:
Septic System Installer Designer
ROBERT B.OUR
P.O. BOX 1539 HARWICH, MA 02643 ���
Phone:
Type of Building:Dwelling Lot Size: 12,196.80 Acres -
Dwdling-No.of Bedrooms: Garbage Grinder:
Other Type of Buildiog: No.of persons: Showers: �.
O[her Fixtures: '�..
Plan Date: Number of Sheets: '�
Cafeteria: '
TiUe: Revisioo Date: �i
Design Flow(mio.required): gpd Calculated design flow: gpd Design Flow provided: gpd '�,
Description of Soils: '��.
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluatioo: �'
DESCRIPTION OF REPAIRS OR ALTERATIONS:MINOR REPAIR-AEPLACE ORANGEBUAG PIPE UNDER CONCRETE PATIO
AND REPIPE TO SEPTIC TANK
The undersignetl agrees W insWll the above tlescribetl Intlivitlual Sewage Disposal System in accordance wHh the provisions of
TITLE 5 and further aarees not to olace in oceratlon until a Certificate of Comollance has been issued 6v the Boartl of Heatth.
Signed Date
Inspections j
�I
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT E55.00
Permission is herby granted to;
� ROBERT B. OUR COMPANY INC., P.O. BOX 1539, HARWICH, MA 02643 �
To perform:Repair-minor an individual sewage disposal system.
Owner: NESSLERNANCIE
C/O BRYAN BOWER
2624 N SAONDERS LAKE DR
MINNETRISTA,MN 55364
Location:9 BEAVER BROOK RD,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDG1S1858,Dated:Apri124,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions
1. MINOR REPAIR-REPLACE ORANGEBURG PIPE UNDER CONCRETE PATIO AND REPIPE TO
SEPTIC TANK
Bruce G. y,MPH, R.S., CHO/Amy L. von Hone, R.S.,CHO
Health Director/Assistant Health Director
T6e issuance of this permit shall not be construed as a guarantee t6at the system will functiou as designed.
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