HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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COMMONWEALTH LTH ®F MASSACHUSETTS
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6# �j ' Board of Health, r i2 OLW!t , MA.
�,/ WWW APPLICATION FOP, DISPOSAL. SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - Complete System ❑ Individual Components
Location
Owner's Name Prnf
Map/Parcel# 7- ,
Address 4 -
Lot#
Telephone#
Installer's NameL
ALI
""-� Designer's Name
Address
-� 1 S Address T
Telephone#
�Telephcne* 2 -
Type
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (minim. required) / / ® gpd Calculated design flow 6S Design flow provided 56O gpd
Plan: Date ='x(�� Zn(T Number of sheets Revision Date Tk7-c • 1 tZb%
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to" the above described Individual Sewage Disposal Stem in accordance with the provisions of TITLE 5 and
further agrees o " of pl ere m in operation until a Certificate of C pli ce h been issued by the Board of Health.
Signed J Date 1
'COMM ONWEAL.TII' OF MASSACHUSETTS
Board of Health, \/4f2-1? 0 U7T4 , MA.
CERTIFICATE Of COMPLIANCE
FEE � 116, 00
C,�-+� Z050
Description of Work:: ❑ Individual Component(s)' a Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (,`{J, Repaired ( ), Upgraded ( ), Abandoned ( )
has been insta4in�accordAie 4A7the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow476 6 (gpd)
Installer
Designer: ` f, x Inspector: ( l ik.,, Date:
The issuance of this permit shall not be construed as a guarfintee that the system will function as designed.
- No.1 �(% l-� �C. "i5 � 05'��,� � t �..•i-�1 t�-1�-5 FEE `P f � �% • Q (�
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �01 , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 11 0-A V IZ1 A, G -E L A N c as described in the application for
Disposal System Construction Permit No. -A,';;-, d , dated
Provided: Construction shall be c6mpletedwithin-dnTrMrs of the date of this permit All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown MA: Date �j %Board of Health '✓ ��°
✓ ��� !, /.r �i .0.7 - X71// J�C_./%7�'�GY% l ; �,. _ .
No.:BOHDC-15-0845
Commonwealth of Massachusetts F�°
s++o.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Application for a Permit to:New Constructiou-Complete System
Lceation: 11 CARRIAGE LN,YARMOUTH PORT, MA 02675 Owner:
SANDY SIDE CORP
Map/Parce�: 112.47.1 P O BOX 525
YARMOUTHPORT,MA 02675
Phone:
Septic System Installer Designer
ROBERT CHILDS INC. DOWN CAPE ENGINEERING,INC.
P.O. BOX 1431 SOUTH DENNIS, MA 939 ROUTE 6A
02660 YARMOUTHPORT,MA 02675
Phone: (508)362-4541
Type of Building:Dwelling Lot Size:0.99 Acres
Dwelling-No.ot Bedrooms:4 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date: 12/09/2014 Number of Sheets: 1 Cafeteria:
Tit1e:SITE PLAN OF 11 CARRIANGE LANE Revision Date: 12/17/2014
Design Flow(min.required):440 gpd Calculated design flow:440 gpd Desigu 11ow provided:560 gpd
DescripHon of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluaror: Date of Evaluafion: 11/06/2014
DANIEL GONSALVES,SE
DESCRIPTION OF REPAIRS OR ALTERATIONS:NEW- 1500 GAL SEPTIC TANK,DBOX,4-500 GAL PRECAST CHAMBERS W/4' �
STONE:42'X 12.83'X 2'
The untlersigned agrees to install!he above tleseribed Individual Sewage Disposal System In accordanee wMh!he provisions of
71TLE 5 and further aarees not to olaee in ooeration until a CerliFlcate of Comollance has heen issued 6v the BoaM et Healtli. �
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FeB
DISPOSAL SYSTEM CONSTRUCTION PERMIT s++o.00
Permission is herby granted to;
ROBERT CHILDS INC., P.O. BOX 1431, SOUTH DENNIS,MA 02660
To perform:New Construction an individual sewage disposal system.
Owner. SANDY SIDE CORP
P O BOX 525
YARMOUTHPORT,MA 02675
Location: 11 CARRIAGE LN,YARMOUTH PORT,MA 02675
Disposal System Consuucrion Permit No.: BOHDC-1S0845,Dated:January 21,2015
Provided:Construction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions
1. BOH TO INSPECT S011 RF_MOVAL
2. NEW- I500 GAL SEPTIC TANK, DBOX, 4-500 GAL PRECAST CHAMBERS W/4'STONE: 42'X
I2.83'X 2'
Bruce G. M�rph ,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 guarantee that the system will funMion as designed.
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FeB
CERTIFICATE OF COMPLIANCE s++o.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; New Construction
by:ROBERT CHILDS INC.
at: 11 CARRIAGE LN,YARMOUTH PORT,MA 026�5
Has been installed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDC-1�0845,dated 07/17/2015.
Installer:ROBERT CHILDS INC.
Address:P.O.BOX 1431 SOUTH DENNIS,MA 02660 Inspector:AMY VON HONE,R.S.
Designer:DOWN CAPE ENGINEERING,INC.
Conditions
1.BOH TO INSPECT SOIL REMOVAL
2.NEW- 1500 GAL SEPTIC TANK,DBOX,4-500 GAL PRECAST CHAMBERS W/4' STONE:
42' X 12.83'X 2' /� /
�f
Bruce G. u y, MPH, 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