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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE r✓rJ r 00 Bot} pc-Is-2� COMMONWEALTH LTH OF MASSACHUSETTS ctf-+o0 6-7 0 - Board of Health, APPLICATION F®I, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - omplete System ❑ Individual Components Location f L� �� L /J Owner's Name CFR),) `"\ Map/Parcel# S Address / !R Lot# Telephone# Installer's Name �Q t- , �v Designer's NameIQ�e-BARS Address � �w�+V� Address Qd �Nij )S Telephone# Telephone# So—91-32, Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ No. of persons Lot Size sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. re uired) gpd Calculated design flow i /© Design flow provided .30 gpd IliPlan: Date _ Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator AM`s UO A k 6N' -Date of Evaluation DESCRIPTION OF REPAIR4,-1 A © 0G4 f 10AJne r—S 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 p e system operation until a Certificate of Comoliance has been issued by the Board of Health. Signed Date LA hp 7 Inspections No. 0kA-DC"'( S=1,,11 -- FEE -C)C) COMMONWEALTH LTH ®F M ASSAC14USETTS Board of Health, y8Ej=M0 V-["i'i , MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) -Cf tGomplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,ij, Upgraded ( ), Abandoned ( ) by: Q epee iT' 's Ole CL Co , X"i C- at has been installed fin. accordai e with the rovisions of 310 CMR 15.00 (Title 5) and the kP proved design plans/as-built plans relating to application No. / 7 /0 L. , dated "% Approved Design DesignFllow (g01 Installer C"Zt57DPOI--L UO(Z 4 ,/-l�� gInspector: Designer: JTt�V� f( vkA /��'' _� Date: The issuance of this permit shall not be construed as a guar that the system will function as designed. 00000 00000:)000 0i: U000.0:10 000 DO O(JO00000000000:J000000O.00U-OOOf!QOOi.0000OD_0(=�'0.t2<10.GL OG1�GQ O 000000.00000000 OC No. N �" S G. :/ -! , C� �Q . FEE �7 0 COMMONWEALTH OF MASSACHUSETTS Board of Health, y/�R aN10 VT}� , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair (-I Upgrade( ) Abandon( ) an individual sewage disposal system at/ % 1 �� t_ � v� C N as described in the application for Disposal System Construction Permit No. / `/ z ; dated Provided: Construction shall be completed within t e-, o tRe date of this plL-rmit.r All local conditions must be met. hie h / Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date 6 ' 6 — / � Board of Health C �� �1 No.: BOHDC-15-2359 � Commonwealth of Massachusetts F� sss.00 Board of Health, Yarmouth, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to:Upgrade-Complete System Location: 18 MISTLETOE LN, SOUTH YARMOUTH, MA 02664 Owner: CLANCY DAVID P Map/Parcel#: 089.52 CLANCY ANNE B&REBECCA A 18 MISTLETOE LN SOUTH YARMOUTH,MA 02664 Phone: Septic System Installer Designer ROBERT B.OUR STEPHEN HAAS.PE P.O. BOX 1539 HARWICH, MA 02643 P.O.BOX 16 Phone: SOUTH DENNIS,MA 02660 (508)362-8132 Type of Building:Dwelling Lot Size: 15,682.00 Acres Dwelling-No.of Bedrooms:3 Garbage Grinder. Other Type otBuilding: No.of persons: Showers: Other Fixtures: Plan Date:OS/18/2015 Number of Sheets: i Cafehria: Tit1e:SEPTIC SYSTEM DESIGN 18 MISTLETOE LANE Revision Date:06/02/2015 Design Flow(min.required):330 gpd Calculated design Flow:330 gpd Design Flow provided:348 gpd Description of SoiIs:SEE PLAN Soil Evaluator Form No.: Name of Soil Eva�uaror: Dah of Evaluation:OS/06/2015 STEPHEN HAAS,PE DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-PAOPOSED 1500 GAL H-20 SEPTIC TANK,H-20 DBOX,2-500 GAL PRECAST H-20 CHAMBERS W/4'STONE:25'X 12.8'X 2' . The undersignetl agrees to install the above tleseribed Indlvitlual Sewage Disposal System in accortlanee with the provisions of 71TLE 5 and further aarees not to olace In ooeration until a Certificate of Comoliante has 6een issued bv the Boartl o1 Heakh. Signed Date Inspections . _ Commonwealth of Massachusetts � Board of Health, Yarmouth, MA Fee DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00 Permission is herby granted to; ROBERT B. OUR COMPANY INC., P.O. BOX 1539, HARWICH, MA 02643 To perform:Upgrade an individual sewage disposal system. Owner: CLANCY DAVID P CLANCY ANNE B&REBECCA A l8 MISTLETOE LN SOUTH YARMOUTH,MA 02664 Location: 18 MISTLETOE LN, SOUTH YARMOUTH,MA 02664 Disposal System Construction Perxnit No.: BOHDC-15-2359,Dated:June 08,2015 Provided:Construction shall be comple[ed within six months of the date of this permit. All local conditions must be met. Conditions L REPAIR-PROPOSED 1500 GAL H-20 SEPTIC TANK, H-20 DBOX, 2-S00 GAL PRECAST H-20 CHAMBERS W/4'STONE:25'X 12.8'X 2' 2. ZONE II MAXIMUM 3 BEDROOMS 3.ALL COMPONENTS H-20 PER PLAN DESIGN � C�'-� Bruce G. urp y, MPH, R.S., CHO/Amy L.von Hone, R.S., CHO Health Director/Assistant Health Diredor The issuance of this permit shall not be construed as a guarautee that the system will function as designed. Commonwealth of Massachusetts Board of Health, Yarmouth, MA FBe CERTIFICATE OF COMPLIANCE sss.00 Description of Work:Complete System The undersigned hereby certify that the Sewage Disposal System; Upgraded by: ROBERT B. OUR COMPANY INC. at: 18 MISTLETOE LN, SOUTH YARMOUTH,MA 02664 Has been installed in acwrdance with the provisions of 310 CMR 15.00(Title 5)and the approved design plans or as-built plans relating to application No.: BOHDG1S2359, dated 06/11/2015. Installer.ROBERT B.OUR COMPANY INC. Address:P.O.BOX 1539 HARWICH,MA 02643 Inspector:AMY VON HONE,R.S. Designer: STEPHEN HAAS,PE Conditions 1.REPAIR-PROPOSED 1500 GAL H-20 SEPTIC TANK,H-20 DBOX,2-500 GAL PRECAST H-20 CHAMBERS W/4' STONE: 25' X 12.8'X 2' 2.ZONE II MAXIMUM 3 BEDROOMS 3.ALL COMPONENTS H-20 PER PLAN DESIGN � Bruce G. Mu hy, 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_D isposal_Construdion_CofC.rpt