HomeMy WebLinkAboutApp-Permit-ComplianceNo. /30/1De-/S—aW
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FEE
LUMMUINWEAUH U1 NIASSACIIUSETTS e ��5
0\�\ Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
,)t/ Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑ Complete System ❑ Individual Components
Location
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Owner's Name
Map/Parcel#
2,
Address S / v/Z
Lot#
Telephone#
Installer's Name
Designer's Name ,
Addressqqo
�h .5
#
Address /L� zAW
Telephone#
Telephone#
Type of Building �P �r�(�P/�I iC�-C� Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building NA. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 4/4/0 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
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no pt�t,
stem in operation until a Cert�cate of Compliance has been issued by the Board of Health.
SignedDate ) _ / S -15-
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1S
CK (P4 r �-1-
Inspections�u UtA>°✓ �16,r ` C >. 41t,
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FEE s
COMMONWEALT14 Of MASSACHUSETTS Z-75
Board of Health, Yi9A0 UT14 , MA.
CERTIFICATE % C®MPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned he%reby"cer ' tha/t the Sewage Disposal System; Constructed ( ), Repaired (1--); Upgraded ( ), Abandoned ( )
by: d,!!u
at It it,
has been installed in ac ordance wit the provisipm_ of 310 CMR 15.00 (Title 5) and the approved desi n pI ns/as-built plans relating to
_
application No. / �'" dated / ` / Approved Design Flow �(gpd) 1
� r J�ic
Installer f'� T / ., _� _ P / (6tr.,n ¢
Designer: 2 L Inspector: //A � Date:
The issuance of this permit slij not be construed as a guarantee that the system will function as designed.
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No. r3o N � c -1 � -d �} � A. k .a t� �--- FEE � 57-5 . 00
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YWM0UT1+ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby,r�a}nted to; Construct
-(-f)Repair (/) Upgrade( ) Abandon( ) an individual sewage disposal system
at EO—
as16�1 i J described in the application for
Disposal System Construction Permit No. /5- _Q -b , dated
Provided: Construction shall be completed within th-e� of the date of this permi . All local conditions must be met.
9� �� r
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date J� �� //Board of Health (/
/ // / �.. C - % A / C_ . /, A,, fir(/ l % � ��s> �✓7
No.:BOHDGIS-0841
� Commonwealth of Massachusetts F�
sss.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Component(s)
Location: 32 BREEZY POINT RD,SOUTH YARMOUTH, MA 02664 Owner:
LEWIS,REENA W
Map/Parcel#: 042.180 5 JANNOR WAY
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
RODNEY FISHER EAS SURVEY,INC.
440 MAIN STREET HARWICH, MA P.O.BOX 1729
02645 SANDWICH,MA 02563
Phone: (5081888-3619
Type of Buddiog:Dwelling Lot Size:0.63 Acres
Dwelling-No.of Bedrooms:4 Garbage Grinder:
Other Type of Building:DUPLEX(1 BEDROOM/3 BEDROOM) No.of persons: Showers:
Other Fizturcs:
Plan Date: 11/07/2014 Number of S6eets:3
Cafeterie:
TitIe:SITE&SEWAGE COMPONENT REPAIR 32 BREEZY POINT ROAD Revision Date: 12/13/2014
Design Flow(mio.required):440 gpd Calculated design flow:440 gpd Design ilow provided:444 gpd �
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: 10/16/20t4
EDWARD STONE,PLS
DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXISTING H-20 1500 GAL SEPTIC TANK,EXISTING 4'H-20 DIAMETER
PIJMP CIIAMBER,DBOX,20'X 30'LEACH F[ELD
The undersigned agrees to install the above describeE Individual Sewage Disposal System In accordance wkhlhe provisions of
� TITLE 5 antl fuAher aareea not to olace in ooere[ion until a Certificate of Comollance has 6een Ias�etl hv[he Bosrtl of Heakh.
Signed Date
Inspections
i �
I
� . Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
RODNEY FISHER SEPTIC SERVICE,440 MAIN STREET, HARWICH, MA 02645
' To perform:Upgrade an individual sewage disposal system.
� Owner. LEWIS,REENA W
5 JANNOR WAY
WEST YARMOUTH,MA 02673
Location:32 BREEZY POINT RD,SOUTH YARMOUTH,MA 02664
Disposal System Construction Percnit No.:BOHDC-1S0841 ,Dated:January 15,2015
Provided:Constructio�shall be completed within six months of the date of this permi[. All local conditions must be met.
Conditions
1. REPAIR-EXISTING H-201500 GAL SEPTIC TANK, EXISTING 4'H-20 DIAMETER PUMP
CHAMBER, DBOX, 20'X 30'LEACH FIELD
2. BOH TO INSPECT SOILS PffiOR TO INSTALLATION
i
Bruce G. Murph , M , R.S., CHO/Amy L.von one, R.S., CHO
He th Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.