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COMMONWEALTH OF MASS C14USETTS c 3q,
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair)/ Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location
13-7 %G
gL4&<Owner's
Name
Map/Parcel#
61)
Address Z%Z ,,q/k--XWf1711 /ice
Lot#
Telephone#
Installer's Name 0 4�
Designer's Name
Address
/I/ a-
IA-oj
Address
Telephone#
ST%Of'-
Telephone#
Type of Building Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
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
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 44.�_ f /r7
-A Pic' �ii�s / .,.. / S, r ��' %I; mor F �O/ !c -
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no lace th in o a Certificate of Compliance has been issued by the Board of Health.
Signed Date l0 — 7
Inspections
COMMONWEALTH OV SSACHUSETTS�;�
Board of Health, C ' 1T?� ,
CERTIFICATE Of COMPLIANCE � v
Description of Work: ❑ Individual Component(s) 0 Complete System
The undersigned hereby certify that tlt Sewage Disposal System; Constructed ( ), Repaired)(), Upgraded ( ), Abandoned ( )
by: D c 1— CG u � ui
at 1�?. 5m
has been installe n acceorcance wit�i b
application No. dated
Installer IDC- MU -411015
s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
Approved Design Flow,_. v� (gpd)
Designer: M Inspector: Date: %d
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
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No. � C�� J` — Z► i .3 tl Accu 3 � - FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y/�12A0 , % M
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(j� Upgrade( ) Abandon( ) an individual sewage disposal system
at 1al MI-DiZ tj I as described in the application for
Disposal System Construction Permit No. /' �� �`� , dated ✓
Provided: Construction shall be completed within4hTee-m=of the ate of this permit. All local conditions must be met.
_>
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, M Date y / Board of Health
No.: BOHDGIS-4645
Commonwealth of Massachusetts Fee
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Repair-minor-Individual Component(s)
Location: 137 ASTOR WAY, SOUTH YARMOUTH, MA 02664 Owner:
HARRISON VIRGINIA
� Map/Parcel#: 125.111 PO BOX 123
YARMOUTH PORT,MA 02673
Phone:
Septic System Installer Designer
ACCUSEPCHECK
17 NORTHSIDE DRIVE SOUTH
DENNIS, MA 02660
Phone:
� Type of Building:Dwelling Lot Size: 14,810.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: No.otpersons: Showers:
Other Fixtures:
Plan Date: Number of Sheets:
Ca&teria:
Title: . Revision Date:
Design Flow(min.required):220 gpd Calculated desigo flow:220 gpd Design flow provided:220 gpd
Description of Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluatioo:
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-MAIOR REPAIR-REPLACE DBOX PER INSPECTION
REPORT
The unde�aigned agrees W installlhe above tlescribed Individual Sewage Disposal System in accordance with the provisions of
T1TLE 5 antl further aarees not to nlace in ooeration until a Certifieate of Comoliance has heen issued hv the Boartl of HeaMh.
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: Repair-minor an individual sewage disposal system.
Owner. HARRISON VIRGINIA
PO BOX 123
YARMOUTH PORT,MA 02673
Locarion: 132 EILEEN ST,SOUTH YARMOUTH,MA 02664
Disposal System Coastruction Permit No.: BOHDGIS-4645,Dated: October 08,2015
� Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be me[.
CONDITIONS:
1. SEPTIC DISPOSAL-MINOR REPAIR-REPLACE DBOX PER INSPECTION REPORT(EXISTING 1000 GAL
SEPTIC TANK,6'LEACH PIT W/2'STONE
VW
Bruce G. M phy, PH, 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 function as designed.