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Board ofHealth, UTI , MA.
APPLICATION FOR ISI P®SAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location -1�
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Owner's Name d%P Ct�P
Map/Parcel#
Address G/1 /1 ' (cl?
Lot#
Telephone#
Installer's Name C��
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Designer's Name
Address >Q , V
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Address
Telephone#
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Telephone#
Type of Building �A D ) Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
gpd Calculated design flow
Number of sheets
Soil Evaluator Form No. Name of Soil Evaluator
OF REPAIRS OR ALTERATIONS
The uni
further
Signed
Inspections
D-6ap<
Design flow provided
Revision Date
Date of Evaluation
Pe
gpd
I A-Adual Sewage Disposal System in accordance with the provisions of TITLE 5 and
until a Certificateg C,?npliT has been issued by the Board of Health.
Date
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No. p5- iq p��
FEE
COMMONWEALTH Of MASSACHUSETTS
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Board of Health, Y-46,' O 0774 , MA.
CERTIFICATE Of COMPLIANCE'
Description of Work:Individual Component(s) ❑ Complete System /),
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (pgraded ( ), Abandoned ( )
by. �cx C C P i' 1S -Q
at c v �' FGr✓(7 ;
has been ins lied In accordance 7t the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application�No. /7 , dated -3 --24 -/!;. Approved Design Flow (gpd)
Installer t C C ( � 5 �C)C-Q l
.
Designer: Inspector: G / Date:
The issuance of this permit shall not be construed as a guaran a that the system will function as designed.
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No. O i�c -15-1 �s � C , . SEPnc bQ ,5P . CU . 5-Mt)C) FEE r 00
COMMONWEAL114 Of MASSACHUSETTS �
Board of Health, YMM D 017k , MA.
➢FISP®SAI. SYSTEM CONSTRUCTION PERMIT
Permission is herebygr me to; onstructQ ) Repair/ Upgrade( ) Abandon( ) an individual sewage disposal system
at
6 VVE0V
as described in the application for
Disposal System Construction Permit No. / :�S- , dated
Provided: Construction shall be completed within t �the date of this permit. -All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 3� /Board of Health
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No.:BOHDC-15-1484 '
Commonwealth of Massachusetts Fee
ass.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT '
Application for a Permit to:Repair-minor-Individual Component(s)
Location: 96 WIMBLEDON DR,WEST YARMOUTH, MA 02673 Owner:
ARNOLD PAUL L
Map/Parcel#: 022.63 ARNOLD PAULA L
96 WIMBLEDON DRIVE
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
BEFORE SUNSET LLC
P.O. BOX 1466 HARWICH, MA 02645
Phone:
Type of Building:Dwelling Lot Size:0.23 Acres '
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Other Type of Building: . No.of persons: Showers:
Other Fixtures:
Plan Date: Number of Sheets: Cafeteria•
Title: Revision Date: I
Design Flow(min.required):220 gpd Calculated design flow:220 gpd Design flow provided: gpd
Description of Soils: I
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluatioe: �
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i
I
DESCRIPTION OF REPAIRS OR ALTERATIONS:NIINOR REPAIR-REPLACE DBOX AND OUTLET TEE PER INSPECTION I
REPORT DATED 12/22/2014
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of i
TITLE 5 and further aarees not to olace in ooeration until a Certificate of Comnliance has heen issued bv the Board of Heakh.
Signed Date I
Inspections
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Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
BEFORE SUNSET LLC, P.O. BOX 1466, HARWICH,MA 02645
To perform:Repair-minor an individual sewage disposal system.
Owner: ARNOLD PAUL L
ARNOLD PAULA L
96 WIMBLEDON DRIVE
WEST YARMOUTH,MA 02673
Location:96 WIMBLEDON DR, WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-1484,Dated:March 23,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
(. ;_ l
Bru G. Murphy,MPH, R.S., CHO/ y L.von Hone, R.S.,CHO
Health Director/Assistant Health Director
i�
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 $55.00
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Repair-minor
by:BEFORE SUNSET LLC
at:96 WIMBLEDON DR, WEST YARMOUTH,MA 02673
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.: OHDC-15-1484,dated 04/03/2015.
Installer:BEFORE SUNSET LLC
Address:P.O.BOX 1466 HARWICH,MA 02645 Inspector:AMY VON HONE,R.S.
Designer:
v
Bru 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.
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BOH_Disposal_Construction_CofC.rpt �
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