HomeMy WebLinkAboutApp-Permit-Compliance071Z—)No. CO G 03C_ y� / 40
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<; Board of Health, Y�4FLMOO TIA , MA.
APPLICATION F®I, DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Apl lication for a Permit to Construct() Repair( ) UpgradeXandon() - 0 Complete System ,Individual Components
Location[COLC I T" C L)I T God c f T
Owner's Name r fl C+
J��-6e s
Map/Parcel#
Address M c i (''c T
Rd,
Lot#
Telephone# g s ! — ?. 3.X — L4 (,-) Li.L
Installer's Name R® JPS rr V Co PC--,
Designer's Name
Address .� { C 5 3 �� ��
Address Pa, K
Telephone# Mg_ 3'2.-Q`5-30
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Lot Size 000sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. equired) 230 gpd Calculated design flow /to Design flow provided gpd
Plan: Datel Number of sheets L` Revision Date
Title
Description of Soils) (
Soil Evaluator Form No.
—L-0
Name of Soil Evaluator &:X at3g Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS l P S'14) � ,D —bO k
C kA mbPT S !,J Fp-d SA N14-
�i 3 �v Lrr.A-ro sem°
The undersigned agrees to ' the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t c e system in operation until a Certificate of Com lia ce has been issued by the Board of Health.
Signed Jl/ Date d
- Inspections
No. «. j ty , .. Z -A6 FEE $ sy. o 0
COMMON LT14 OF MASSACHUSETTS rYl'�-
Board of Health, YA:e-MOl3TI-1 , MA. �4C 5-
CERTIFICATE OF COMPLIANCE 47
Description of Work: W(ndividual Component(s) .. ❑ Complete System
.The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.4 Upgraded ( ), Abandoned( )
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at C" i r r t s i"T PA C -b < "'r - ---
has been installed inraccc
application No. f�
Installer GN ( l 51-V I
,vitf;'f e"prdvisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
dated Approved Design Flow �i .� (gpd)
Designer: IaAS S Q-1\AQ C—T-�Gd Q Inspector: Date:
P
The issuance of this permit shall not be construed as a gua tee that the system will function as designed.
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No. t){t C `.5-- 2��� (� � - FEE ,53,", 110
COMMONWEALTH Of MASSAC14USETTS c r� `77
Board of Health, )LA&MO 01-4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( �)^ Repair(v/ Upgrade( ) Abandon( ) an individual sewage disposal system
at j a e t t' c i ) t 'i' 8-4P,C. AS-<' / as described in the application for
Disposal System Construction Permit No. /moi —//�- , dated 6
•-/.; -2-3,67
Provided: Construction shall be completed within tis o date of this pe�in't. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 6 -/lF %f CBoard of Health .�
No.:BOHDC-IS-2367
. Commonwealth of Massachusetts FeB
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Component(s)
Location: 12 CIRCUIT RD EAST,WEST YARMOUTH, MA 02673 Owner:
DERBES TRACEY A
Map/Parcel#: 049.68 22 ADLEY DR
ABINGTON,MA 02351
Phone:
Septic System Installer Designer
ROBERT B.OUR BASS RIVER ENGINEERING
P.O. BOX 1539 HARWICH, MA 02643 P.O.BOX 1163
Phone: EAST DENNIS, MA 02641
(5081385-3426
Type of Building:Dwelling Lot Size:4,792.00 Acres
Dwelliog-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: No.ot persons: Showers:
Other Fixtures:
PlanDate:05/22/2015 NumberofSheets: l Cafeteria:
Tit1e:SITE PLAN l2 CIRCUIT ROAD EAST Revision Dah:
Design Flow(min.required):220 gpd Calculahd design Flow:330 gpd Design Flow provided:334 gpd
Description of Soils:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Dah of Evaluation:OS/07/2015
THOMAS MCLELLAN,P.E.
� DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXISTING 1000 GAL PLAST[C TANK,DBOX,24 QUICK 4 STANDARD
INFILTRATORS W/OUT STONE:26'X 12'X 8"
The undersigned agrees to insfall the above deseribed Individual Sewage Disposal System in aecordance with the provisions of
� TITLE b and further aarees not to olace in ooeration until a Certificate of Comoliance has heen isaueA hv the Board of Meakh.
Signed Date
Inspections
Commonwealth of Massachusetts
° Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is herby granted to;
ROBERT B. OUR COMPANY INC., P.O. BOX 1539, HARVNCH, MA 02643
To perform:Upgrade an individual sewage disposal system.
Owner: DERBES'IRACEYA
22 ADLEY DR
ABINGTON,MA 02351
Location: 12 CIRCUIT RD EAST,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-2367,Dated:June 16,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be me[.
CO�dit1011S
1. REPAIR-EXISTING 1000 GAL PLASTIC TANK, DBOX, 24 QUICK 4 STANDARD INFILTRATORS
W/OUT STONE. 26'X 12'X 8"
2. MFC VARIANCE: 1. SETBACKS TO PROPERTYLINE
Bruce ur hy, MPH, R.S.,CHO/Amy L.von Hone, R.S., CHO
Health Director/Assistant Health Diredor
T6e issuance of this permit shall not be construed as a guarantee t6at the system will funMion 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; Upgraded
by:ROBERT B. OUR COMPANY INC.
at: 12 CIRCUIT RD EAST, WEST YARMOUTH,MA 02673
Has been installed in accordance with the provisions of 310 CMR 15.00(TiUe 5)and the approved
design plans or as-built plans relating to application No.: BOHDC-IS-2367,dated 06/25/2015.
' Installer:ROBERT B.OUR COMPANY INC.
Address:P.O.BOX 1539 HARWICH,MA 02643 Inspector:AMY VON HONE,R.S.
Designer:BASS RIVER ENGINEERING
Conditions
1.REPAIR-EXISTING 1000 GAL PLASTIC TANK,DBOX,24 QUICK 4 STANDARD
INFILTRATORS W/OUT STONE:26' X 12' X 8"
2.MFC VARIANCE: 1.SETBACKS TO PROPERTY LINE /� �O��L �n
�7� X�%
Bruce G. Murphy, MP , 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 guarantee that the system will function as designed.
BO H_Disposal_Construction_CofC.rpt