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Board of Health, . )&MD Qn4 , JWA.
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APPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade0 4 Abandon( ) - omplete System O Individual Components
Location �j��
Owner's Name
Map/Parcel#
Address b~�
Lot#
Telephone#
Installer's Name
Designer's Name
Address /
Address �D /
Telephone#47
Telephone# i — P/
Type of Building Lot Size 12, l�' ® sq. ft.
Dwelling - No. of Bedrooms arbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 44!;�� Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS � !/'/2!�
Date of Evaluation
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 lace the system in operatic til a Certificate of Compliance has issued by the Board of Health.
Signed Date 7 //-&-
Inspections
V*
No.FEE
f M ASSAC14USETTS t
�®NINI®N�I.TII � i;Board of Health,iY1Ql�}f MA. / L
CERTIFICATE,,Of COMPLIANCE ��bI�=�6-oo
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Description of Work: 0 Individual Component(s) mplefe System
The undersig d hereby certify that the Sewage Disposal System; Constructed( ), Repaired,(_ ), Upgraded (v), Abandoned ( )
�y at
has been instalied m accordance wiz , / 'ovisions of 310 4R 15.00' (Title 5) and,the a proved design plans/as-built plans relating to
applicatiop„ c /L� �lJ -3 ,dated J's� / .',Approved Design Flow (gpd)
Installer � ! ..0 - �,.
r 1
Designer: Inspector:', U, ! 1 M Date:
{
The issuance of this t shall not be construed as a guAL4tee that the system will function as designed _
No.
Cis S fi 'j�'t .Y��=li'►4 t� }"'
COMMONWEALTH LTH Of,,M ASSACHUSETTS
Board of Health, YMNdLfrg
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade+ -I Abandon( ) an individual sewage disposal system
FEE $.S5- 00
Ck -g/2,2-
at �i / .!4-t a' J .'` .r &rE2Z 0 1. r�° T_,/ fel ij�
Disposal System Construction Permit No. /'C;-- �l)3 , dated y /�
Provided: Construction shall be completed+within thT4eji.@4r--spf tthhe date of this
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date f Boardof Health
as described in the application for
must be met.
No.:BOHDC-15-4463 '
' Commonwealth of Massachusetts Fee '
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Application for a Permit to:Upgrade-Complete System
Location: 51 GORDON LN,YARMOUTH PORT, MA 02675 Owner:
HITCH JEAN L LIFE EST
Map/Parcel#: 114.80 51 GORDON LN
YARMOUTH PORT,MA 02675
Phone:
Septic System Installer Designer
CHASE&MERCHANT STEPHEN HAAS,PE
P.O. BOX 5 DENNISPORT, MA 02639 P.O.BOX 16
Phone: SOUTH DENNIS,MA 02660
508-362-8132
Type of Building:Dwelling Lot Size: 13,068.00 Acres
Dwelling-No.of Bedrooms:4 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:08/13/2015 Number of Sheets: 1 Cafeteria•
Tit1e:SEPTIC SYSTEM DESIGN 51 GORDON LANE Revision Date:
Design Flow(min.required):440 gpd Calculated design flow:440 gpd Design flow provided:454 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:07/22/2015
ST'EPHEN HAAS,PE
� DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,H-20 DBOX,
3-500 GAL PRECAST CHAMBERS W/4'STONE:33.5'X 12.8'X 2'
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 nlace in ooeration until a Certificate of Comoliance has been issued bv the Board of Health.
Signed Date
Inspections
�
�
I
� �
� Commonwealth of Massachusetts
: .
Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
�
Permission is herby granted to;
CHASE&MERCHANT INC., P.O. BOX 5, DENNISPORT, MA 02639
To perform:Upgrade an individual sewage disposal system.
Owner: HITCH JEAN L LIFE EST
51 GORDON LN
I YARMOUTH PORT,MA 02675
I
' Location:51 GORDON LN,YARMOUTH PORT,MA 02675
Disposal System Construction Permit No.: BOHDC-15-4463,Dated:September 18,2015
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, H-20 DBOX,3-500 GAL PRECAST
CHAMBERS W/4'STONE: 33.5'X 12.8'X 2'
2.ZONE II MAXIMUM 4 BEDROOMS
L�
Bruce . 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.
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�
�
�
�
� Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
� CERTIFICATE OF COMPLIANCE $55.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:CHASE&MERCHANT INC.
at: 51 GORDON LN,YARMOUTH PORT,MA 02675
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.: BOHDC-15-4463,dated 10/19/2015.
�
�' Installer:CHASE&MERCHANT INC.
Address:P.O.BOX 5 DENNISPORT,MA 02639 Inspector:PHILIP RENAUD
Designer: STEPHEN HAAS,PE
Bruce G. Murphy, P , 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 t the system will function as designed.
BO H_Disposal_Construction_CofC.rpt