HomeMy WebLinkAboutApp-Permit-ComplianceQ N
Uj
�I
C, 8L-b�- KI00L/6& (o
d8 /4HE COMMONWEALTH OF MASSACHUSETTS
ll
FEE
�M
�;� BOARD OF HEALTH / ,4-176 Q°
/ C/1010"�J OF % " l �-' '/ " `-'� / ! �(J X �Qe�Y,�l �!✓f /
'LICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
)n for a Permit to Construct ( ) Repair ( ) Upgrade (,/Abandon E]Complete System ndividual Components
�2 Lot# NF1+ Vim/
Y�1_ [aller'sName��J
Telephon #
Owner's Name
Address
T one #
Designer's Name
(5ce 56AA?ess
Telephone #
Type of Building: Lot Size Sq. feet
Dwelling — No. of Bedrooms Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (mi re ired)gpd Calculated design flown Ogpd Design flow provid gpd
Plan: Date Number of sheets Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIP'T'ION OF REPAIRS OR ALTERATIONS . t &
Date of Evaluation
I u.LFlii
The undersign e agrees to in tall the above describeff Individ I Sewage Disposal System in accordance with the provisions of
TITLE 5 and further rees not to the sy in oper 'on until C rtificate of Compliance has b en iss ed by the Board of Health.
Signed Date
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
-yu+rrNo. v DC —15--689.3 THE COMMONW ALTH OF MASSACHIJ3 TS —% /IKE 5z_ 0
/<1f Z BOARD OF HEALTH
C IFICATE OF COMPLIANCE Z�' 2z ter/-
Description of Work: Individual Com onent s Com lete S stem
P P () ❑ P Y
The undersi ee�d hhnerre�ebyvicertify that theme ,Se'wage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned
at l�i� 3
has been installed in accor rice with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating t application o. /�� '� dated '� _._ / Approved Design Flow _(gpd)
Installer
Designer: �� %� 1" IA Inspector Date S
The issuance of this certificate shall not be construed as guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
C,4" AL e61V5M ,
No. 004])C-I5.0(913l-HE COMMONWEALTH OF MASSACHUSETTS FEE S5.00
BOARD OF HEALTH a-7* 175—
DISPOSAL SYSTEM CONSTR CTION PERMIT
Permission is hereby granted to Construct ) Repair (Upgrade ( ) Abandon ( ) an individual sewage
disposal system at as described
in the application for Disposal System Construction Permit No. lS`4-Z- dated
Provided: Construction' shall be completed within tl .3=sof the date of this permi A411 conditions must be met.
Date 'T " ` j 6 - " Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
.�` FORM 1255 (REV 5/96) H&W HOBBSE& WARRENT" PUBLISHERS - BOSTON
No.:BOHDC-15-0893
• Commonwealth of Massachusetts Fee
E55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Component(s)
Location: 12 AVERY LN, SOUTH YARMOUTH, MA 02664 pWo¢�;
ZELNICK,ROBYN L �
Map/Parcel#: 099.77 SPEVACK,Ti-IEODORE P
12 AVERY LN
S YARMOUTH,MA 02664
Phone:
Septic System Installer Designer
CARDINAL DAVID B.MASON.R.S.
32 RIDGETOP ROAD COTUIT, MA 4 GLACIER PATH
02635 E. SANDWICH,MA 02537
Phone: (508)833-2177
Type of Building:Dwelling Lot Siu:0.40 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fistures:
Plan Date:Ol/10/2015 Number of Sheets: 1
Cafeteria:
Title:S]TE AND SEWAGE PLAN 12 AVERY LANE Revisioo Date:
Design Flow(min.required):330 gpd Calculated desigo flow:330 gpd Design flow provided:350 gpd
Descrip[ion of Soi1s:SEE PLAN
' Soil Evaluator Form No.: Name of Soil Evaluaror: Date of Evaluatioo: 12/11/2014
DAVID B.M.4SON,R.S.
' DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,16
HIGH CAPACITY INFIL7RATORS W/OUT STONE:25'X 113'X 11"
The untlersigned agrees to install the above tleseribed Individual Sewage Disposal Sysbm in aeeordance wlth the provisions of
TITLE 5 antl furfher aarees not to olace In ooeration untll a Cerfifieate of Comollance has heen issued bv tAe eoard of Heakh.
Signed Date
Inspections
i �
Commonvvealth of Massachusetts
Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
CARDINAL CONSTRUCTION, 32 RIDGETOP ROAD, COTUIT,MA 02635
To perform:Upgrade an individual sewage disposal system.
Owner: ZELNICK,ROBYN L
SPEVACK,THEODOREP
12 AVERY LN
S YARMOUTH,MA 02664
Location: 12 AVERY LN,SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDG1S0893,Dated:Apri106,2015
Provided: Construc[ion shall be completed wi[hin six months of the date of this permit. Ali local condi[ions must be met.
Conditions
1. SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK, DBOX, 16 HIGH CAPACITY
INFILTRATORS W/OUT STONE: 25'X 11.3'X 11"
2. ZONE II M�IXIMUM 3 BEDROOMS
L V� ,,
Bruce G. Murp , H, R.S., CHO/Amy L.von Hone, R.S.,CHO
alth Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarantee t6at the system will function as designed.
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
CERTIFICATE OF COMPLIANCE $55.00
Description of Work: Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by: CARDINAL CONSTRUCTION
at: 12 AVERY LN, SOUTH YARMOUTH, MA 02664
Has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved
design plans or as -built plans relating to application No.: BOHDC-15-0893, dated 05/01/2015.
Installer: CARDINAL CONSTRUCTION
Address:32 RIDGETOP ROAD COTUIT, MA 02635 Inspector: AMY VON HONE, R.S.
Designer: DAVID B. MASON, R.S.
Conditions
1. SEPTIC DISPOSAL - REPAIR - EXISTING 1000 GAL SEPTIC TANK, DBOX, 16 HIGH
CAPACITY INFILTRATORS W/OUT STONE: 25'X 11.3' X 11"
2. ZONE II MAXIMUM 3 BEDROOMS
BruceeMdrphy, MPH, 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.
BOH_Disposal_Construction_CofC. rpt