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No. 1� ' rZ ! FEE
COMMONWEALT14 Of MASSACHUSETTS
�;? ! 'id Board of Health, , MA.
44PLICATI®N FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
ation for a Permit to Construct( ) Repair( ) Upgrade Abandon() - ❑ Complete System lrJ Individual Components
Location
Owner's Name
Map/Parcel# (l�Z
Address J'
L
Lot#
Telephone#
s
Installer's Name
` Designer's Name
U
Address �Q
Address
Telephone# e e
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) 33 gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further s to not to place the system in op e tion until a Certificate of Compli a has been issued by the Board of Health.
Signed / �,� Date c �I le5—
Inspections
E
COMMONWEALTH LTH ®E MASSACHUSETTS o4 -
Board
-Board of Health,VA-ai"1/1, n t}T}'}' � , MA
C
CERTIFICATE Of COMPLIANC�
Description of Work Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (_ }; Abandoned ( )
by:
at
ha:
apl
Ins
Designer: Inspector: / > Date: 7'" / Y / >
The issuance of this permit shall not be c nstrued as a guaranteee that the system will function as designed.
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No. —1777 f liS a Me -?Lt A-tZ " FEE L2
?6 COMMONWEALTH OF MASSACHUSETTS
Board of Health, _VA4Z fb'S� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (t,'-)' Abandon( ) an individual sewage disposal system
at ' as described in the application for
Disposal System Cons uctton Permit N/�oo..� � L- dated
Provided: Construction shall be completed w' hin of the date of this permit All local cpnditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA ! Dates_ - , B and o ealth
�uf/,� � ,�..���.a/. /11 �G,' ��''� / .- � r//`•� .�. //dIl T / ��'i�1�� �,®i� :) �`'1 `�`%!'.o'_� �•-L� T7"� 1!/f -i ➢.��.� !_°/}ri
i , _
. No.:BOHDC-15-1791
Commonwealth of Massachusetts F�
E55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to: Upgrade-Individual Component(s)
Location: 57 LONGFELLOW DR,WEST YARMOUTH, MA 02673 Owner:
WALL PETER D
Map/Parcel#: 151.98 WALL MARIE L
57 LONGFELLOW DR
YARMOUTH PORT,MA 02675
Phone:
Refuse Hauler Designer
CHASE&MERCHANT, MORAN ENGINEERING ASSOC..LLC
P.O. BOX 5 941 ROUTE 28
Phone: HARIWCH,MA 02645
(5081432-2878
Type of Building:Dwelling Lot Size: 15,246.00 Acres
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Futures:
Plan Date:08/11/2014 Number of Sheets:2
Cafehria:
Tit1e:SEPTIC SYSTEM DESIGN 57 LONGFELLOW DRIVE Revision Date:
� Design Flow(min.required):330 gpd Calculated design ilow:330 gpd Design flow provided:330 gpd
Description ot Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:OS/18@014
DAN CROTEAU,P.E.
- DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXISTING 1000 GAL SEPTTC TANK,DBOX,20 QU[CK 4 HIGH
CAPACITY INFILTRATORS W/OUT STONE:FIELD CONFIGURATTON 1.84'X 17'
• The untlersigned agrees W Insfall Ne above tlescribed Individual Sewage Dlsposal System in accortlance wKh the provisions of
- 717LE 5 and further aarees not to olace in ooeration unHl a CertHicate of Comoliance has heen issued bv the Board of Neakh.
Signed Date
Inspec[ions
Commonwealth of Massachusetts
' Board of Health, Yarmouth, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT Fee
ass.00
Permission is herby granted to;
CHASE & MERCHANT INC., P.O. BOX 5, DENNISPORT, MA 02639
To perform: Upgrade an individual sewage disposal system.
Owner: WALL PETER D
� WALL MARIE L
57 LONGFELLOW DR
�. YARMOUTH PORT,MA 02675
ILocation: 57 LONGFELLOW DR, WEST YARMOUTH, MA 02673
Disposal System Construction Permit No.: BOHDGIS-1791 , Dated: May 07,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions
1. BOH&ENGINEER TO INSPECT AND CERTIFYSOILS AND SYSTEMINSTALLATION
2. WATERLINE TO BE SLEEVED
3. REPAIR-EXISTING 1000 GAL SEPTIC TANK, DBOX, 20 QUICK 4 HIGH CAPACI7YINFILTRATORS
W/OUT STONE: FIELD CONFIGURATION 1.84'X 17'
�/
Bruce G phy, MPH, R.S., CHO/A y 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.
i
I
I
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FeB
CERTIFICATE OF COMPLIANCE ass.00
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:CHASE&MERCHANT INC.
at:57 LONGFELLOW DR,WEST YARMOUTH,MA 02673
Has been installed in accordance with the provisions of 3]0 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDGIS-1791,dated 07/15/2015.
Installee CHASE&MERCHANT INC.
Address:P.O.BOX 5 DENNISPORT,MA 02639 Inspector:AMY VON HONE,R.S.
Designer:MORAN ENGINEERING ASSOC.,LLC
Conditions
1.BOH&ENGINEER TO INSPECT AND CERTIFY SOILS AND SYSTEM INSTALLATION
2.WATERLINE TO BE SLEEVED
3.REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,20 QUICK 4 HIGH CAPACITY
INFILTRATORS W/OUT STONE: FIELD CONFIGURATION k �r 17�
V
Bruce G. Mu hy,MPH, R.S., CHO/Amy L.von Hone, R.S.,CHO
Health Direc[or/Assistant Health Diredor
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
BOH_Disposal_Construction_CofC.rpt