HomeMy WebLinkAboutApp-Permit-ComplianceNo. -lam l J'� 2,q 8-0 �4peell lk i � 4 FEE
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/ —i/�' COMMO LT14 Of MASSACHUSETTS
17,E Board of Health, 4-0MO an , MA.
APPLICATION FOR � S� L SYSTEM CONSTRUCTION RMIT
y A lication for a Permit to Construct( ) Repair )Upgrade() Abandon() - ❑ Complete System Individual Components
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Location
Owner's Name
Map/Parcel#' ' fo
Address
Lot#
Telephone#
Installer's Name COV s�
CDC) 1 Designer's Name
Address
Address
Telephone# 507 T10 .1%00
Telephone#
Type of Building ' '11` Lot Size
Dwelling - No. of Bedrooms
Other -Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
The uni
further
Signed
Inspections
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Name of Soil Evaluator Date of Evaluation
(�►5ceR.
'es to " tall th ove d 1?r�ciindividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
to ce th operation until a Certificate of Compliacne has been issued by the Board of Health.
Date (0-22""7/
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No. /y- C®I�MONWEALT14®F SSAC14YJSETTS �� rG ft) .FEE ,,. (��� ��• .�
Board of Health, Y/�'%if1o1011i7a ,
CERTIFICATE OF COMPLIANCE � 'p
Description of Work: dividual Component(s) ❑ Complete System
The undersigned hereby ert y that the Sewage Disposal Syste�• Constructed ( ), Repaired (/ pgraded ( ), Abandoned ( )
b Co ' �.O( = PJc �� j�il�C'f (�i� 5c"K ?
I
w
y. �� C
at
has been installed Tiiaccordand
application No. PT W/ :_
Installer :Jix( � P ((
wiCiZi tie p Visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated �6 _2Q_ �/ � Approved Design Flow (gpd)
0
Designer: Inspector: fflll Date: Y 1
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. _ 5 2-4s, o Y✓�ty c- 1� l) E�-r LL FEE
COMMONWEALTH OF MASSACHUSETTS 4M it, 577
Board. of Health, `/b t.l`M , MA.
DISPOSAL SYSTiE®NSTRUCTI®N PERMIT
Permission is
hereby granted to; Construct( ) Repair ) Upgrade ( ) Abandon( ) an individual sewage disposal system
at J C,� ���• as described in the application for,
Disposal System Construction Permit No. i , dated w
Provided: Construction shall be completed within this o the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, M Date i Board of Health jaze
i
No.:BOHDGIS-2480
� Commonwealth of Massachusetts F�
sss.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Repair-minor-Individual Component(s)
LocaHon: 358 CAMP ST,WEST YARMOUTH, MA 02673 Owner:
Y00 MATTHEW W
Map/Parcel#: 062.31 Y00 C JEANNE7TE
358 CAMP STREET
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
BEFORE SUNSET LLC
P.O. BOX 1466 HARWICH, MA 02645
Phone:
Type of Building:Dwelling Lot Size: 15,682.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Buildiog: No.of persons: Showers:
Ot6er Fixtures:
Plan Date: Number of Sheets:
Cafehria:
TiHe: Revision Dafe:
Desigo Flow(min.required):220 gpd Calculated design ilow:220 gpd Design flow provided:440 gpd
Description of Soils:
Soil Evaluator Form No.: Name of Soil Evsluator. Date oP Evaluation:
DESCRIPTION OF REPA[RS OR ALTERATIONS:MINOR REPAIR-REPLACE EXISTING DBOX WITH RISER PER INSPECTION
REPORT TO EXISTING I000 GAL SEPTTC TANK AND 3 FLOWDIFFUSORS W/3'STONE
The unde�signed agrees W install the above described Individual Sewage Disposal System in accortlanee with the provisions of �
TITLE b and further aarees not to nlace in ooeration unBl a Certifieate of Comolfance has heen issued bv the Board of Neakh. ��.
Signed Date �'�.
Inspections
i : Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F88
DISPOSAL SYSTEM CONSTRUCTION PERMIT s�.00
I
' Permission is herby granted to;
BEFORE SUNSET LLC, P.O. BOX 1466, HARWICH, MA 02645
To perform:Repaio-minor an individual sewage disposal system.
Owner: YOOMA7"I"I�IEW W
Y00 C]EANNETTE
358 CAMP STREET
WEST YARMOUTH,MA 02673
Location:358 CAMP ST,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-1S2480,Dated:June 22,2015
Provided: Construc[ion shall be completed within six months of the date of this permit. All bcal conditions must be met.
I Conditions
1. MINOR REPAIR-REPLACE EXISTING DBOX WITH RISER PER INSPECTION REPORT TO
EXISTING 1000 GAL SEPTIC TANKAND 3 FLOWDIFFUSORS W/3'STONE
�V G1�1
Bruce G urphy,MPH, R.S., CHO/Amy L.von Hone, R.S., CHO ',
Health Diredor/Assistant Health Diredor '�
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 ass.00
IDescription of Work: Individual Component(s)
iThe undersigned hereby certify that the Sewage Disposal System; Repair-minor
by:BEFORE SUNSET LLC
at: 358 CAMP ST,WEST YARMOUTH,MA 02673
Has been installed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved
I design plans or as-built plans relating to application No.: BOHDG1S2480,dated 06/24/2015.
Installer:BEFORE SLJNSET LLC
Address:P.O. BOX 1466 HARWICH,MA 02645 Inspector:BRUCE MURPHY,R.S.
�� Designer:
Conditions
1.MINOR REPAIR-REPLACE EXISTING DBOX WITH RISER PER INSPECTION REPORT
TO EXISTING 1000 GAL SEPTIC TANK AND 3 FLOWDIFFUSO W/3' STO
�(Q�
Bruce G. Mu , H, R.S., CHO/Amy L. von Hone, R.S.,CHO
Health Director/Assistant Health Diredor
The issuance oFthis permit shall not be construed as a guarantee that the system will function as designed.
BOH_Disposal_Construction_CofC.rpt