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COMMONWEALTH Of MASSACHUSETTS
Board of Health, YAfAM OT14 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct(t/Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location Q U l
Owner's Name IS V
Map/Parcel# Q (, -7
AddressOF 60jQ+&V-
Lot#
Telephone# 69,13
Installer's Name �, LJ �' T�L,
Designer's Name
Address ?q L
Address
Telephone# _ _
Telephone#
Type of Building Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS KLA i) 11C C 001 3
sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
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 agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ZeIZ --
Inspections
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COMMONWEALTH Of MASSACHUSETTS
SETTS
Board of Health, 6tY , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ti Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:iZOb eg" - 12Ot ?- CO, 10 C,
at .,fit)
has been installe in accdi' a c� 50 tl
application No. j i dated
Installer l" th21 ST1J�/f.
Designer:
ins of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
L . Approved Design Flow (gpd)
Inspector:
Date: / /,
The issuance of this permit shall not be construed as a guanwi ee that the system will function as designed.
00 J. i" o C, 0 o u_io, e o C- coo 0", C n 0 r: 1 a 000 -pnoo0 Ott-[3-c-�-Crri_-�-n.UO_o-0 Jo 0c?C)�nonr_)O-c IUJU�r�C'.����OCOG(�UO000Qo'O"o.O.otl ;joGf9 Coo(.or,
No. C -1.SS- 025-- / R . Rj . CJ 0 (Z.. FEE r V
/ �--. /-3 2 COMMONWEALTH Of MASSACHUSETTS "' ""�0G 0 -3
Board of Health, l A"D t H -W
DISPOSAL S YST CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repai Upgrade ( ) Abandon ( ) an individual sewage disposal system
at /08 004-490L MAIM!= JQQW as described in the application for
Disposal System Construction Permit No. dated
,
Provided: Construction shall be completed within Lee ye o the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date—7 r Board of Health
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
CERTIFICATE OF COMPLIANCE 555.00
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Repairvminor
by:ROBERT B. OUR COMPANY INC.
at: 108 QUARTERMASTER ROW,SOUTH YARMOUTH,MA 02664
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�0259,dated 07/10/2015.
Installer:ROBERT B. OUR COMPANY INC.
Address:P.O.BOX 1539 HARWICH,MA 02643 Inspector:AMY VON HONE,R.S.
Designer: CRAIG SHORT,P.E.
Conditions
1.MINOR REPAIR-REPLACE DBOX TO EXISTING 1500 GAL SEPTIC TANK,5 HIGH
CAPACITY INFILTRATORS W/STONE:34'X ll'X 11° �/ /�iL/��Jtt=�Y/
U vrT
Bruce G. M h , PH, 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.
BO H_Disposal_Construction_CofC.rpt
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT E55.00
Permission is herby granted to;
ROBERT B. OUR COMPANY INC., P.O. BOX 1539, HARWICH, MA 02643
To perform:Repair-minor an individual sewage disposal system.
Owner. VIRGIN CHRISTOPHER
VIRGIN CANDACE
66 CAPTAIN PRESTONS RD
DENNIS,MA 02638
Location: ]08 QUARTERMASTER ROW,SOUTH YARMOUTH,MA 02664
Disposal System ConsWction Permit No.: BOHDGIS-0259,Dated:July 08,2015
Provided: Construction shall be completed wi[hin six months of the date of[his permit. All local conditions must be met.
Conditions
1. MINOR REPAIR-REPLACE DBOX TO EXISTING 1500 GAL SEPTIC T.9tVK, 5 HIGH CAPACITY
INFILTRATORS W/STONE:34'X 11'X 11"
�v��
Bruce G. Murb�PH, 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 gua#antee that the system will function as designed.
No.:BOHDC-15-0259
Commonwealth of Massachusetts Fee
555.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Repair-minor-Individual Component(s)
Location: 108 QUARTERMASTER ROW, SOUTH YARMOUTH, MA Owner:
02664 VIRGIN CHR[STOPHER
Map/Parcel#: 077.67 VIRGIN CANDACE
66 CAPTAIN PRESTONS RD �
DENNIS,MA 02638
Phone:
Septic System Iustaller Designer
ROBERT B.OUR CRAIG SHORT,P.E.
P.O. BOX 1539 HARWICH, MA 02643
Phone:
508-385-6530
Type of Buildiog:Dwelling Lot Size: 14,810.00 Acres
Dwelling-No.of Bedtooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:06/09/1997 Number of Sheets: 1 Cafeteria:
TitIe:PROPOSED SEPTTC DESIGN l08 QUARTERMASTER ROW Revision Date:
Design Flow(min.required):330 gpd Calculated design tlow:330 gpd Design ilow provided:332 gpd
Description of Soi1s:SEE PLAN
Soil Evaluatar Form No.: Name of Soil Evaluator: Date of Evaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:MINOR REPAIR-REPLACE DBOX TO EXISTING 1500 GAL SEPTIC TANK,5
HIGH CAPACTTY INFILTRATORS W/STONE:34'X 11'X 11"
The undersigned agrees to install the above described Individual Sewage Dlsposal System in accortlance with!he provisions of
TITLE 5 and furfher aarees not to olace in ooeratfon untll a Certificafe of Comoliance has heen issued bv the Boartl of HeaRh.
Signed Date
Inspections