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HomeMy WebLinkAboutApp-Permit-ComplianceFEE No. ®► X, COMMON LTH Of MASSACHUSETTS O'� Board of Health, Agm0oly MA. APPLICATION FOR rDISPOSAL SYSTEM CONSTRUCTI®N PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components Location d L Ls Owner's Name 0/0 r7-optl 77or'lL Map/Parcel# 010 L r 3 Address S ��► 1�G QC�uf Lot# lj Telephone# 5 -of q 7 t 01,%,� Installer's Name �� `� Designer's Name Address /VS t Address Telephone# O -776 7 t{7 Telephone# Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil (s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS gpd Calculated design flow Number of sheets Nam Soil Evaluator 1 - Design flow provided Revision Date Date of Evaluation gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to of 1 e the in op ation until a Certificate of Compliance has been issued by the Board of Health. Signed - Date Inspections No. 60" WDC -15- (� T `� /�_6 q COMMONWEALT14 Of MASSACHUSETTS Board of Health, Y&D ( T-0 MA. CERTIFICA E ©r COM I.IANCf Description of Work: X11dividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), by: at </,/- //v has been installed d9 ,TX ce with the prb. application No. /<-j6 1�_ , dated Installer a -o S C -P (4 P /W 7) N, Aj FEE . �0 ( ) , Abandoned ( ) of 310 CMIR 15.00 (Title 5) and the approved design plans/as-built plans relating to �;_ . Approved Design Flow (gpd) Designer: Inspector:/ � Date: The issuance of this permit shall not be construed as a guar ee that the system will function as designed. No. FaAi�U —g Via' 8� �p - 4C—C.4U FEE COMMONWEALTH OF MASSACHUSETTS' Board of Health, _Y49—M O VT H , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission its hereby granted to; Construct( ) Repair Upgrade ( ) Abandon( ) an individual sewage disposal system at a i u -s P4T-)* as described in the application for Disposal System Construction Permit No. , dated"�. til l %C-/14,4 Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chades wn, MA Date_. -/C-.Board of Health LI , , No.: BOHDGIS-1846 Commonwealth of Massachusetts Fee ass.00 Board of Health, Yarmouth, MA APPLICATION FOR DISPOSAL SYSTEM CON5TRUCTION PERMIT Application for a Permit to:Repair-minor-Individual Component(s) Locatian: 40 JILLS PATH,WEST YARMOUTH, MA 02673 Owner: AHRONIAN ELIZABETH(LIFE ES'1) Map/Parcel#: 066.35 40 JILLS PATH WEST YARMOUTH,MA 02673 Phone: Septic System Installer Designer ACCUSEPCHECK 17 NORTHSIDE DRIVE SOUTH DENNIS, MA 02660 Phone: Type otBuilding:Dwelling Lot Siu: 18,295.20 Acres Dwelling-No.otBedrooms:3 Garbage Grinder: Other Type of Building: No.ot persons: Showers: Other Fixtures: Plan Date: Number of Sheets: Cafeteria: Title: Revision Date: Design Flow(min.required):330 gpd Calculahd design f1ow:330 gpd Design flow provided:330 gpd Description ot Soils: Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: DESCRIPTION OF REPAIRS OR ALTERATIONS:MINOR REPAIR-SEAL TANK,REPLACE DBOX,SANITARY TEES INCLUDING GAS BAFFLE PER INSPECTTON REPORT BY ACCU SEPCHECK The untle�signed agrees to install the above deseribetl Individual Sewage Disposal System in accordance with the provisions of TITLE 5 antl further aarees not to olace In oceration until a Certificate of Comoliance has heen issued bv the eoard of Heakh. Signed Date Inspections , , Commonwealth of Massachusetts Board of Health, Yarmouth, MA Fee DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00 Permission is herby granted to; ACCU SEPCHECK, 17 NORTHSIDE DRIVE, SOUTH DENNIS, MA 02660 To perform:Repairvminor an individual sewage disposal system. Ownec AHI2ONIAN ELIZABETH(LIFE FST) 40 JILLS PATH WEST YARMOUTH,MA 02673 Locaiion:40 JILLS PATH, WEST YARMOUTH,MA 02673 Disposal System Construction Permit No.: BOHDG1S1846,Dated: Apri124,2015 Provided: Construction shall be completed within six mon[hs of the date of this permit. All local condi[ions must be met. Conditions 1. MINOR REPAIR-SEAL TANK, REPLACE DBOX, SANITARY TEES INCL UDING GAS BAFFLE PER INSPECTION REPORT BYACCU SEPCHECK � Bruce G. 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. Commonwealth of Massachusetts Board of Health, Yarmouth, MA F� CERTIFICATE OF COMPLIANCE sss.00 Description of Work: Individual Component(s) The undersigned hereby certify that the Sewage Disposal System; Repair-minor by:ACCU SEPCHECK at:40 JILLS PATH, WEST YARMOUTH,MA 02673 Has been installed in accordance with the provisions of 3l0 CMR 15.00(Title 5)and the approved design plans or as-built plans relating to application No.: BOHDC-15-1846,dated 04/24/2015. Installer: ACCU SEPCHECK Address:l7 NORTHSIDE DRIVE SOUTH DENNIS, Inspector:AMY VON HONE,R.S. MA 02660 Designer: Conditions 1.MINOR REPAIR-SEAL TANK,REPLACE DBOX,SANITARY TEES INCLUDING GAS BAFFLE PER INSPECTION REPORT BY ACCU SEPCHECK ��A� G�-}°/'7 l�/ Bruce G�fphy, MPH, R.S., CHO/Amy L.von Hone, R.S., CHO Health Diredor/Assistant Health Direc[or The issuance of this permit shall not be construed as a guarantee that the system will function as designed. BOH_Disposal_ConsVuction_CofC.rpt