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No. �C �0�� / FEE
COMMONWEALTH ®
Board of Health, Y�%1 O l� �i , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad0'-) Abandon() - -Cl Complete System O Individual Components
Location V U
Owner's Name
Map/Parcel#Address
-.d
Lot#
Telephone#
Installer's Nam
Designer's N
Address '012 G
Address
Telephone#
Telephone#
Type of Building Lot Size /Z / �'6 sq. ft.
Dwelling - No. of Bedrooms 'Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow providedSY �___ gpd
Plan: Date j I % 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
(�'b py�[.�•�� S ���•'c `�� (.tome-�t�iti `� /�:ti f �?•�/�/lc_ /r"GYr4s�
The undersigned ees to install above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agro t to plate em in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed - Date
No.tVDc-1s_(0(9 %x" \ E I 1<25
COMMONWEALTH OF MASSACITURS 1(-- V15� a
Board of Health, VA ! M4 MA. j
CERTIFICATE Of COMPLIANCE
Description of Work: J21ndividual Component(s) U-etimplete System
The undersigned hereby certify that the Sewafe Disposal System; Constructed (y-,"RRepaired ( ), Upgraded Abandoned (
has been installeiPin'actS6Mafic-e'withPI
of 310 CMR 15.00 (Title 5) and,thepproved design plans/as-built plans relating to
Designer: ,14-,o .t Inspector: `� , �/�' ��.Y B Date:
The issuance of this pernut shall not be construed as a guaradkee that the system will function as designed
No. i C — 5-4v164 CA" l Mme• C_,".577 .fil Cn0j&J FEE ��i -
00
/ - - `fib COMMONWEALTH Of MASSACITUSETTS t. -#/zG3
Board of Health, Vkmolwl , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(44" Upgrade(.. -Y' Abandon ( ) an individual sewage disposal system
at _;6� -5- A±L_ t'7 22eas described in the application for
Disposal System Construction Permit No. /L� dated,/.L..- �
Provided: Construction shall be c
MD,
within ars of the date of this perm�it� All local conditipns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Oard f Heal't�i
No.:BOHDGIS-6184
• Commonwealth of Massachusetts Fee
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Complete System
Location: 5 AUTUMN DR, SOUTH YARMOUTH, MA 02664 Owner:
ANISH WAYNE A
Map/Parcel#: 059.59 AIVISH LINDA S
22 BEACH ST
MILLBURY,MA 01527
Phone:
� Septic System Installer Designer
CARDINAL DAVID B.MASON,R.S.
32 RIDGETOP ROAD COTUIT, MA 4 GLACIER PATH
02635 EAST SANDWICH,MA 02537
Phone:
' 5084201295 508-833-2177
Type of Building: Lot Size: 12,197.00 Sq.Ft.
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Ot6er Fixtures:
Plan Date: I 1/06/2015 Number of Sheets: 1 Cafeteria:
Tit1e:SITE AND SEWAGE PLAN 5 AUTUMN DRIVE Revision Date:
, Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:349 gpd
Description of Soi1s:SEE PLAN
. Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:09/10/2015
DAVID B.MASON,R.S.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,2-
500 GAL PRECAST CHAMBERS W/4'STONE:25'X 12.83'X 2'
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further aarees not to olace in ooeration until a Certificate of Com�liance has been issued bv the Board of Health.
Signed Date
Inspections
. Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is herby granted to;
CARDINAL CONSTRUCTION,32 RIDGETOP ROAD, COTUIT, MA 02635
To perform:Upgrade an individual sewage disposal system.
Owner: AriISH WAYNE A
AIJISH LINDA S
j 22 BEACH ST
� MILLBURY,MA 01527
i
Location:5 AUTUMN DR, SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDC-15-6184,Dated:December 14,2015
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-PROPOSED 1500 GAL SEPTIC TANK, DBOX,2-500 GAL PRECAST
CHAMBERS W/4'STONE:25'X 12.83'X 2'
2.ZONE II MAXIMUM 3 BEDROOMS
� V�
I Bruce G. Mur y, PH, R.S., CHO/Amy L.von Hone, R.S.,CHO
� ealth Director/Assistant Health Director
(
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
1
!
i
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
�
CERTIFICATE OF COMPLIANCE sss.00
;
� Description of Work:Complete System
�
� The undersigned hereby certify that the Sewage Disposal System; Upgraded
i by:CARDINAL CONSTRUCTION
at: 5 AUTUMN DR,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-15-6184,dated 12/15/2015.
1
� Installer:CARDINAL CONSTRUCTION
Address:32 RIDGETOP ROAD COTUIT,MA 02635 Inspector:AMY VON HONE,R.S.
j Designer:DAVID B.MASON,R.S.
Conditions
1.SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,2-500 GAL
; PRECAST CHAMBERS W/4'STONE:25'X 12.83'X 2'
i
! 2.ZONE II MAXIMUM 3 BEDROOMS
i � �
' Bruce G. Murp , H, R.S., CHO/Amy L.von Hone, R.S., CHO
i Health Director/Assistant Health Director
I
I
; The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
i
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BO H_Disposal_Construction_CofC.rpt