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FEE
COMMONWEALTH OF MASSACHUSETTSc1L,42�5
Board of Health, Yta,R.r��.r , MA. �Q O0 �O S
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade.(,)-A15andon() - atomplete System ❑ Individual Components
Location
Owner's Name H
Map/Parcel#
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Address 1 b t-
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Lot#
Telephone# cj0q -
Installer's Name
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Designer's Name
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Address j 1 f1
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Address I: -77:2)/t
Telephone# 5
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Telephone#
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Type of Building r--4 -c Lot Size /- , Jl ( sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. reuired) gpd Calculated design flow �� a Design flow provided �-_ pd
Plan: Date J -2,1 l j 5 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
The undersigned agrees to install the above
further agrees tM24&I
lace the m in,
Signed
Inspections
No
Name of Soil Evaluator
150co
Date of Evaluation
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Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
until a Certificate of Co liance been issued by the Board of Health.
Date 7%B `L<
COMMONWFALT14 OF MASSAC14USETTS
Board of Health, )6a: Mb rrl , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: D Individual Component(s) Fal'l omplete System
The and signed hereb certify that the lSewage Disposal System; Constructed( ), Repaired ( ),Upgraded,( - Abandoned ( )
by: -
atr ���yr -ck ( M 0
r,)ri
has been instalacc Ida e Pi tkle p olions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicagn-N � -1..2_ , dated 7 % Approved Design Flow i d)
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Installer �k A i (- i s � 'n� l . of ' �- ��' 'r ,erG 1. �
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The issuance of this permit shall of be construed as a guarn ee that the tem will funeti Date: 7 -
The
Win._ + Inspector: �;a
' p gu system on as designed.
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No.6ii(1-)c- CA V AM 0 FEE
/S --/ �-, (r. COMMONWEALTH Of MASSACHUSETTS ~4 230'0
Board of Health, yA QZM0 Mj: , M.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygrantedto; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at r 1 I f 1 T - T as described in the application for
Disposal System Construction Permit o. / , dated
Provided: Construction shall be comap%ted within thie,-r f the d&Ae of this it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestawn, MA Date I' / J Board of Health
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No.:BOHDGIS-0134
' 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: 78 STARBUCK LN,YARMOUTH, MA 02675 Owner:
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MAHON MARK
' Map/Parcel#: 115.140 78 STARBUCK LN
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' YARMOUTH PORT,MA 02675
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Phone:
' Septic System Installer Designer
� B&B EXCAVATION ENGINEERING WORKS,INC.
14 TEABERRY LANE FORESTDALE, 12 WEST CROSSFIELD RD
MA 02644 FORESTDALE,MA 02644
Phone: 508-477-5313
Type of Building:Dwelling Lot Size: 14,810.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder:
Ot6er Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:OS/21/2015 Number of Sheets:2 r
Cafeteria:
Tit1e:PROPOSED SEPTTC SYSTEM UPGRADE PLAN 78 STARBUCK LANE Revision Date:
Design Flow(min.required):220 gpd Calculated design flow:220 gpd Design flow provided:355.2 gpd
Description of Soi1s:SEE PLAN �
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:OS/13/2015
PETER MCENTEE,PE
DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-PROPOSED 1500 GAL POLYTANK,DBOX,20 ADS ARC 36HD UNITS
W/OUT STONE:20'X 14.2'X 7" '
� 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 nlace in o�eration until a Certificate of Comoliance has been issued bv the Board of Health. I
Signed Date �
Inspections
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, Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
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� Permission is herby granted to;
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B&B EXCAVATION, 14 TEABERRY LANE, FORESTDALE, MA 02644
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i To perform:Upgrade an individual sewage disposal system.
Owner: MAHON MARK
78 STARBUCK LN ',
YARMOUTH PORT,MA 02675
Location: 78 STARBUCK LN,YARMOUTH,MA 02675
Disposal System Construction Permit No.: BOHDGIS-0134,Dated:July 06,2015
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions
1 REPAIR-PROPOSED 1 S00 GAL POLYTANK, DBOX, 20 ADS ARC 36HD UNITS W/OUT STONE:20'
X 14.2'X 7"
2. ZONE II MAXIMUM 2 BEDROOM
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Bruce G. A�FGrp y, MPH, R.S., CHO/Amy L.von Hone, R.S., CHO I,
Ji' 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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