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No. f/o -,,r vL ' 16v — 7a9 FEE
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S l C® ® LTII OF MASSAC14USETTS
Board of Health, yt1 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System__Q4 dividual Components
Location
Owner's Name
Map/Parcel# i 7
Address
Lot#
Telephone# '� —436 3
Installer's Name ucthoI
, Designer's Name +�
Address / —7
,/ L
�� Address R3 ✓ "! s I
Telephone#Telephone#
� 2-
Type of Building f CQ Lot Size a ,lw— sq. ft.
Dwelling - No. of Bedrooms -13 Garbage grinder ( )
Other - Type of Building
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ® gpd Calculated design flow _ 3 6 Design flow provided gpd
Plan: Date Number of sheets 2— Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator 140 n,4jnN Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersi ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a s to 0 o place the m in o 'on until a Certificate of Compliance has been issued by the Board of Health.
Signed A Date Zi J
Inspections
t
No. �W �F'!� i�.� FEE
— 2 � COMMONWEALTH Of SSACIIUSETTS16 '�
Board of Health, YA4A 0 t T1+
CERTIFICATE Of COMPLIANCE
Description of Work:vidual Component(s) ❑ Complete System
The undersized hereby certify tha th Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,4- , Abandoned ( )
by: .
at ! i , -A n rieli 4'... --r) (-l ei f' ._ _rL uf��t�
has been installedin`acct'rdarictil'with'fht lVoAsions of 310 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
applicatipnrIalp. /�� / _, dated /� / A proved Design Flow and
Installer JJ r a� /�
Designer.(W fit�r C �t 1%at j Inspector: Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
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No.0 C ---l5-2-971 % + C�(CAVXTION FEE c aO
COMMONWEALTH Of MASSACHUSETTS Z4
Board of Health, YAMD MI , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( )
at d
Upgrad&(—'Y--A—bandon ( ) anindividual sewage disposal system
as described in the application for
Disposal System Construction Permit No. % , dated
-7/
Provided: Construction shall be completed within tbx@e years of thq date ofIs
per n t. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadesInn, MA Date 8 r//—/ - Board (gHeal /L,/
, No.:BOHDC-15-2871
Commonwealth of Massachusetts Fee
sss.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
. Application for a Permit to:Upgrade-Individual Component(s).
Location: 11 APACHE DR YARMO TH .
, U ,MA 02675 Owner.
� HERVARTH LIDIJA
. Map/Parcel#: 143.148 OZOLS &CRONIN
� 11 APACHE DR
YARMOUTH PORT,MA 02675-2103
Phone:
Septic System Installer Designer
B&B EXCAVATION DOWN CAPE ENGINEERING,INC.
� 14 TEABERRY LANE FORESTDALE, 939 ROUTE 6A
' MA 02644
Phone:
YARMOUTHPORT,MA 02675
508-362-4541
Type of Building:Dwelling Lot Size: I6,9SS.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fisturcs:
Plan Date:OS/03/2015 Number of Sheets: I
Cafeteria:
Tide:TITLE 5 SITE PLAN ll APACHE DRNE Revision Dah:
Design Flow(min.required):330 gpd Calculahd design Oow:33 gpd Design 11ow provided:369 gpd
Descriptioo of SoiIs:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluaror. Date of Evaluatiou:07/28/2015
DANIEL GONSALVES,SE
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,3-500
' GAL PRECAST CHAMBERS W/4'STONE:33.5'X 12.83'X 2'
The unde/signed ag�ees W insfal�the above tlescribetl Individual Sewage Disposal3yatem In aceordance wkh the provisions of
TITLE 5 anA further aorees not W olaee in ooerafion until a CertiFcate of Cemoliance has 6een issued 6v the Boartl of XeaMh.
Signed Date
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
� DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
�
i
Permission is hereby granted to;
B&B EXCAVATION, 14 TEABERRY LANE, FORESTDALE, MA 02644
To perform: Upgrade an individual sewage disposal system.
Owner: HERVARTH LIDUA
OZOLS &CRONIN
� 11 APACHE DR
YARMOUTH PORT,MA 02675-2103
Location: 11 APACHE DR, YARMOUTH, MA 02675
Disposal System Construction Permit No.: BOHDC-15-2871 , Dated: August 11,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
CONDITIONS:
1. SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK, DBOX, 3-500 GAL
PRECAST CHAMBERS W/4'STONE: 33.5'X 12.83'X 2'
2. ZONE II MAXIMUM 3 BEDROOMS(SMALL PORTION OF LOT OUTSIDE ZONE II)
�-�l
Bruce G. Murphy, H, .S., CHO/Amy L. von Hone, R.S., CHO
He th 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
Descriprion of Work: Individual Component(s)
The undersigned hereby certify thaz the Sewage Disposal System; Upgraded
I by:B&B EXCAVATION
� at: 11 APACHE DR,YARMOUTH,MA 02675
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-1S2871,dated O8/18/2015.
Installer:B&B EXCAVATION
I Address:l4 TEABERRY LANE FORESTDALE,MA Inspector.AMY VON HONE,R.S.
� 02644
i Designer:DOWN CAPE ENGINEERING, INC.
���
� . Bruce G. Mu y, PH, R.S., CHO/Amy L.von Hone, R.S., CHO
I Health Director/Assistant Health Diredor
I,
IThe issuance of this permit s6a11 not be construed as a guarantee that the system will function as designed.
BOH_Disposal_Construction_CofC.rpt