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No. `�YC'r5-(0Qr0 THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
NJ Fa�m�l
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade (,<Abandon ( ) - �mplete System []Individual Components
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Telephone #
Type of Building:
Lot Size
�. �� Sq-teet— S
Dwelling — No. of Bedrooms 2 _
Garbage Grinder ( )
Other — Type of Building
No. of persons
Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (mij. r qu' d gpd
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Calculated des i n flow
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gpd Design flow provided 7T /gpd
Plan: Date I
:.
Number of sheets
Revision
Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator `{ a�IhDate
of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1!500 Rai H 16 1410"%_
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu grees not to plat the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 1217
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Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No i3�Fl�C—IS—b�1 J T COMMONWE LTH OF MASSA USE
T4
X' 1—>J ((� BOARD OF HEALT
C RTIFICATE OF COMPLIANC
Description of Work: ❑ Individual Component(s) E�<omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired
at 0 J '%_� ( 1
has been installed in
plans relating4o
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Installer V t l C
No. % Ali %dated Z->
Designer _IJQ U . r 11 it i ( D( E ( 1 11 LU 1 VX Vnspecto:
The issuance of this certificate shall not be construed as a
FORM 3 - CERTIFICATE OF COMPLIANCE
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pgraded idoned ( )
0 CMR 15.00 (Title 5) and the approved design plans/as-built
/ Approved Design Flow (gpd)
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(A Date
/.1 a that the system will function as designed.
DEP APPROVED FORM 5/96
6+ F,' eX CA Vern 01\1
N,. 6W D(J-b+1�HE OMMONWEALTH OF MASSACHUSETTS FEE $5�.0o
BOARD OF HEALTH C."
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gr ynted to Constr ct ( ) Repair ( } Upgrade_(- Abandon ( ) an individual sewage
disposal system at Si �i lett G 10 Wit a Cl TQt�.t.%� as described
in the application for Disposal System Construction Permit No.3a7 , dated
Provided: Construction shall be completed within-thfee-yeftrs-qf f)}e date of this permit. A 1 cal conditions must be met.
Date /Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS& WARREN TM PUBLISHERS - BOSTON
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No.:BOHDGIS-6115 I
- 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: 83 CAPT BACON RD, SOUTH YARMOUTH, MA 02664 Owner:
CURLEY KATHLEEN V TRS
Map/Parcel#: 078.269 CURLEY EDWARD JOSEPH
83 CAPT BACON RD
SOUTH YARMOUTH,MA 02664
Phone:
Septic System Installer Designer
B&B EXCAVATION DAVID B.MASON,R.S.
14 TEABERRY LANE FORESTDALE, 4 GLACIER PATH
MA 02644 EAST SANDWICH,MA 02537
Phone: 508-833-2177
5084770653
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Type of Building•Dwelling Lot Size: 13,068.00 Sq.Ft.
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building• No.of persons: S6owers:
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Other Fixtures: �
.
Plan Date: 12/Ol/2015 Number of Sheets: 1 Cafeteria• �
_ Tit1e:SITE AND SEWAGE PLAN 83 CAPTAIN BACON ROAD Revision Date: �
Design Flow(min.required):220 gpd Caiculated design f1ow:220 gpd Design flow provided:349 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: 11/24/2015 '
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 Comnliance has been issued bv the Board of Heakh.
Signed Date
Inspections
Commonwealth of Massachusetts '
' Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
B&B EXCAVATION, 14 TEABERRY LANE, FORESTDALE,MA 02644
To perform:Upgrade an individual sewage disposal system.
Owner: CURLEY KATHLEEN V TRS
CURLEY EDWARD JOSEPH
83 CAPT BACON RD
SOUTH YARMOUTH,MA 02664
Location: 83 CAPT BACON RD,SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDC-15-6115,Dated:December 28,2015
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 2 BEDROOMS
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Bruce G. urp y,MPH, 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.
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Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
CERTIFICATE OF COMPLIANCE $ss.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:B&B EXCAVATION
at: 83 CAPT BACON RD,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.: BOHDGIS-6115,dated Ol/11/2016.
Installer:B&B EXCAVATION
Address:l4 TEABERRY LANE FORESTDALE,MA Inspector:AMY VON HONE,R.S.
02644
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'
2.ZONE II MAXIMUM 2 BEDROOMS ; i
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Bruce G. urphy, MPH, 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.
BOH_Disposal_Construction_CofC.rpt ;
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