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COMMONWEALTH Of MASSACHUSETTS 10
Board of Health, YA-e..rno 0-1-W , MA. � �;�( l ieY4
APPLICATION FOP DIS OSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System tlrIndividual Components
Location
fR140 Owner's Name �(
Map/Parcel#
-,77 Address
Lot#
Telephone#
Installer's Name
j Designer's Name
Address
Address ]/
Telephone#
b �� Z Telephone# °� j -17
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building o. of persons
Other Fixtnres
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) '10 gpd Calculated design flow Design flow provided3 ✓rr gpd
Plan: Date Number of sheets / Revision Date
Title
Description of Soils) i�� ,4'a n.
Soil Evaluator Form No. Name of Soil Evaluator /7,
DESCRIPTION OF REPAIRS OR ALTERATIONS
of Evaluation 41-- �J
sWj-
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 ��'/ !vy�L Date ;7 /.
Inspections
No. f,ZS L C -'�"' C 1 5 ' tE
COMMONWEALT14 OF MASSAC14USETTSok 7 -37 -tom
Board of Health IMM D 074 MA.
CERTIFICATE OF CONIPLIA CL
Description of Work: ]'Individual Component(s) ❑ Complete System
The undersigned hereby certify th t,the Sewage Dis 1 al System; Co�tructed O, Repaired ( ), Upgraded ( ), Abandoned ( )
by: ,AA
at �L ((, ti��--
has been installed it 4'o ,W4W ih J oY�sions of hO CMR 15.00 (Title 5) and the approveddesign plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer ��% . /�c�l�c�! , ( d� / _ // /�.l ��,�/ J-)p/���
Designer:K c ��1g Inspector: �� '_ Date: —/
The issuance of this permit shall not be construed as a guaran a th t the system will function as designed.
No.5 '265 FEE_tl�
COMMONWEALTH Of MASSAC14USETTS I C
Board of Health,---��U�l� ; MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted
.to;
. Construct( )
at ? 17 r:1 i l ' � , ie" -6
lam
( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit q; , dated
t
Provided: Construction shall be corn ed thin jhreey -Ars of the date of this perp j . /All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, Mn Date / BoarcTfHealtf
,
No.:BOHDC-15-2495
:
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: 39 SWIFT BROOK RD, SOUTH YARMOUTH, MA 02664 Owner:
LEONARD SYDNEY EVA
Map/Parcel#: 067.272 360 MT AUBURN ST#401
CAMBRIDGE,MA 02138
Phone:
Septic System Instailer Designer
BOSETTI SEPTIC RONALD J.CADILLAC,PLS,RS,PC
199 CHURCH STREET EAST P.O.BOX 258
HARWICH, MA 02645 WEST YARMOUTH,MA 02673
Phone: 508-775-9700
Type of Building:Dwelling Lot Size: 11,326.00 Acres
� Dwelling-No.of Bedrooms:2 Garbage Grinder•
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:OS/07/2015 Number of Sheets• 1 Cafeteria• '
TitIe:SITE PLAN FOR 39 SWIFT BROOK ROAD Revision Date:
Design Fiow(min.required):220 gpd Calculated design flow:220 gpd Design flow provided:355 gpd '
Description of Soils:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:04/27/2015 .
RONALD J.CADILLAC,RS
' DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,20 ADS ARCH 36HC
UMTS W/OUT STONE: 11.6'X 25'X 0.89'
, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance wkh the provisions of
TITLE 5 and further aarees not to olace in ooeration until a Certificate of Comoliance has been issued bv the Board of Health.
Signed Date
Inspections
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Commonwealth of Massachusetts
' Board of Health, Yarmouth, MA Fee
' DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
Permission is herby granted to;
BOSETTI SEPTIC SYSTEMS, 199 CHURCH STREET, EAST HARWICH, MA 02645
To perform:Upgrade an individual sewage disposal system.
Owner: LEONARD SYDNEY EVA
360 MT AUBURN ST#401
CAMBRIDGE,MA 02138
Location:39 SWIFT BROOK RD, SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDGIS-2495,Dated:June 24,2015
Provided:Construction shall be completed within six months of the date of this permit. All locai conditions must be met.
Conditions
1. REPAIR-EXISTING 1000 GAL SEPTIC TANK, DBOX, 20 ADS ARCH 36HC UNTI'S W/OUT STONE:
11.6'X 25'X 0.89'
2. ZONE II MAXIMUM 2 BEDROOMS
��
I
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 desigaed.
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Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
� CERTIFICATE OF COMPLIANCE 555.00
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:BOSETTI SEPTIC SYSTEMS
at:39 SWIFT BROOK 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.: BOADC-15-2495,dated 06/29/2015.
Installer:BOSETTI SEPTIC SYSTEMS
Address:199 CHURCH STREET EAST HARWICH,MA Inspector:AMY VON HONE,R.S.
02645
Designer:RONALD J.CADILLAC,PLS,RS,PC
Conditions
1.REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,20 ADS ARCH 36HC UNITS W/OUT
STONE: 11.6'X 25'X 0.89'
2.ZONE II MAXIMUM 2 BEDROOMS ��Q�/���/
Br G. Murphy, 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.
BO H_Disposal_Construction_CofC.rpt
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