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M — b� COMMONWFALT14 OF MASSACHUSETTS
Board of Health,F�em d�_, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A lication for a Permit to Construct( ) RepairK Upgrade( ) Abandon() - 0 Complete System,nndividual Components
Location
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Owner's Name
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Map/Parcel#1a.
Address
Lot#
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Installer's Name
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Designer's Name
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Address
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Address `O ,
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Telephone#
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Telephone #
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Type of Building c`�'. \ Lot Size Q , DC05 sq. ft.
Dwelling - No. of Bedrooms 2 ` Garbage grinder( )
Other _ Type of Building No. of persons 2 Showers ( 1�,<afeteria
Other Fixtures cyo� S lr JSY�c`1Y
Design Flow (min. required) ,�17v gpd Calculated design flow Y"b (1)
Plan: Date 1 "cam
Title
Description of Soil (s)
Soil Evaluator Form 1
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided ,5a gpd
Revision Date
Date of Evaluation I 1 " I -t-15
The undersigne ees to tall ee de 'bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
urther agree o not to ace the emAn o ration til a Certificate of Compliance has been issued by the Board of Health.
Signed Date
L�-
Inspections 2- z Cavi
No. 60t+y c E-
COMM®N LT1I Of MASSACHUSETTS�
Board of Health, ykg& 61 of MA.
CERTIFICATE OF COMPLIANCE'
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certifythatthe Sewage Disposal System; Constructed ( Repaired, ), Upgraded ( ), Abandoned ( )
by: �)��+ s->vie� ,t��coA &\
at
has been install d9 ' aCc�r e wit0he provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. `-0 dated tit- Approved Design Flow -/ ._C -a (gpd)
Installer
Designer:�Inspector: Date: ry
w%
The issuance of this permit shall not be construed as a guar• tee that the system will function as designed.
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COMMONW ALT14 Of MASSACHUSETTS
Board of Health, �a%1 tfiH , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(A Upgrade( ) Abandon( ) an individual sewage disposal system
at C ����r��r ,cc`'� c ;��r 1 C,fS1 j as described in the application for
Disposal System Construction Permit No. �� ��� dated /1 .
Provided: Construction shall be completed within of the date of this per it. ,All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date la Board of Health
� No.:BOHDGIS-6611
, Commonwealth of Massachusetts Fee
` $55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Component(s)
Location: 61 RANDOLPH RD,YARMOUTH PORT, MA 02675 Owner:
PAYNE BARBARA J
Map/Parcel#: 123.70 PAYNE THOMAS M
61 RANDOLPH RD
YARMOUTH PORT,MA 02675
Phone:
Septic System Installer Designer '
SHAY CARMEN E. SHAY ENVIRONMENTAL SER�
P.O. BOX 1576 MASHPEE, MA 02649 P.O.BOX 1576
Phone: MASHPEE,MA 02649
5083947498 508-294-7498
Type of Building:Dwelling Lot Size: 12,197.00 Sq.Ft.
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date: 12/21/2015 Number of S6eets:2 Cafeteria•
Tit1e:PLOT PLAN OF PROPOSED SEPTIC SYSTEM UPGRADE 61 Revision Date: '
• RANDOLPH ROAD
Design Flow(min.required):220 gpd Calculated design flow:220 gpd Design flow provided:444.52 gpd
� Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: 11/19/2015
CARMEN E.SHAY,R.S.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,20
HIGH CAPACITY H-20 INFILTRATORS W/OUT STONE:31.75'X 12.83'X 11"
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 oneration until a Certificate of Comnliance has been issued 6v the Board of Health.
Signed Date
i
Inspections
� e
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
Permission is herby granted to;
SHAY ENVIRONMENTAL, P.O. BOX 1576, MASHPEE, MA 02649
To perform:Upgrade an individual sewage disposal system.
Owner: PAI'NE BARBARA J
PAYNE THOMAS M
61 RANDOLPH RD
YARMOUTH PORT,MA 02675
Location:61 RANDOLPH RD,YARMOUTH PORT,MA 02675
Disposal System Construction Permit No.: BOHDGIS-6611 ,Dated:January 06,2016
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-EXISTING 1000 GAL SEPTIC TANK, DBOX,20 HIGH CAPACITY H-20
INFILTRATORS W/OUT STONE: 31.75'X 12.83'X 11"
2. MFC VARIANCE APPROVAL:a. DEPTH OF LEACH
?
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.
.