HomeMy WebLinkAboutApp-Permit-Compliance. No. 610 5 �{ �� Q x-76^
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COMMONWEALTH Of MASSAC14USETTS
Board of Health, X19 �YVIo�?T?� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT on Ll
Application for a Permit to Construct( ) Repair( ) Upgrade /Abandon( ) - ❑ Complete System C�`individual Components
Location ' D
Owner's Name
Map/Parcel#
Address (}
Lot#
Telephone# 7 % I - '► g' - g !S 6
Installer's Name
Designer's Name
Address 4
Te a l
Address
Telephone# 50k
_
Telephone#
Type of Building VE`- 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)
Plan: Date
Title
Description ofSoil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Design flow provided �'„-v gpd
Revision Date
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1 J i -r %LjT
L
The undersigiwtrWees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire s to to place theem ' p ration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections /
No. lJ« E $55-00
1 C^ F, C®�' MO LTII ®f SSACHUSETTS � ��/7S CA -t�- s ori �
FAM
Board of Health, OT)l , MA. � ! 7�(� �C� L�.:►%
CERTIFICATE OF COMPLIANCE
V�_
Description of Work: ❑ Individual Component(s) ❑ Complete System
Therunnd�ersilTed hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ),Abandoned ( )
by: i1.LxL6y6-Aiojj
at n i!i�ll-f)i n1 ri n o _. i -i(rnoL,,ih0/)r.-
has been installed in accordan a ;& a ,visionfs of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
q-�
application No. /-C, dated � ->--`7 /> . Approved Design Flow (gpd)
Installer
Designer: Inspector:l4�0 - ,,/ Date:
The issuance of this permit shall not be construed'as a guaraq*e that the system will function as designed.
No. 1 -4 -DC --15 37c -f FEE
6 COMMONWEALTH OF MASSACHUSETTS cA-4 One
Board qfjhkalth, � d1�Jd 07 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at
Repair(x) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No ��'G , dated i� :;P4
Provided: Construction shall be competed within three years of the date of this perm All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date t Board of Health
No.:BOHDGIS-1859
Commonwealth of Massachusetts F�
ass.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
i Application for a Permit to:Repair-minor-Individual Component(s)
i
; Location: 10 CONCORD LN,YARMOUTH PORT, MA 02675 Owner:
KELLY ELEANOR S
�. Map/Parcedf: 116.3 168 HIGH ST
, WINCHESTER,MA 018903337
Phone:
' SepNc System lostaller Designer
B& B EXCAVATION
14 TEABERRY LANE FORESTDALE,
MA 02644
Phone:
Type of Building:Dwelling Lot Size: 1Q890.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder.
� Other Type of Buiiding: No.of pereons: Showers:
� OtherFixtures:
Plan Date: Number of Sheets: Cafeteria:
Title: . Revisiao Date:
Design Flow(min.required):330 gpd Calculated design Flow:330 gpd Design Flow provided:330 gpd
Description of Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:MINOR REPAIR-NEW 1500 GAL SEPTIC TANK PEA INSPECTION REPORT
DATED 12/OS/14 BY B&B EXCAVATION
. The undersignetl agrees to install the above descrl6ed Individual Sewage Disposal System in accordance with the provlsions of
' TITLE 5 and further aareea not tn olace in ooeratlon until a Certificate of Comoliance has heen Issued bv the Boartl of HeaHh.
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
� Permission is herby granted to;
B&B EXCAVATION, 14 TEABERRY LANE, FORESTDALE, MA 02644
To perform: Repair-minor an individual sewage disposal system.
� Owner. KELLY ELEANOR S
168 HIGH ST
WINCHESTER,MA 01890-3337
Location: 10 CONCORD LN,YARMOUTH PORT,MA 02675
Disposal System Construction Permit No.: BOHDC-15-1859,Dated:Apri124,2015
Provided: Construction shall be completed within six months of the date of this permit. All loca(condi[ions must be met.
Conditions
I. MINOR REPAIR-NEW I500 GAL SEPTIC TANK PER INSPECTION REPORT DATED 11/OS/14 BY
B&B EXCAVATION
��U"`' LG�1�
Bruce G. Murp MPH, R.S., CHO/AmyL.von Hone, R.S., CHO
,Health Director/Assistant Health Diredor
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
� CERTIFICATE OF COMPLIANCE ass.00
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Repair-minor
by:B&B EXCAVATION
at I0 CONCORD LN,YARMOUTH PORT,MA 02675
Has been installed in accordance with the provisions of 310 CMR 15.00(TiUe 5)and the approved
j design plans or as-built plans relating to application No.: BOHDC-1S1859,dated 04/30/2015.
� Insta(ler:B&B EXCAVATION
' Address:l4 TEABERRY LANE FORESTDALE,MA Inspector:AMY VON HONE,R.S.
i 02644
� Designer:
� Conditions
� 1.MINOR REPAIR-NEW 1500 GAL SEPTIC TANK PER INSPECTION REPORT DATED
12/OS/14 BY B&B EXCAVATION //��G�< �;,"�_
i�l� u/Q�i/
Bruce G. Myrphy, PH, 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_Construdion_CofC.rpt