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COMMONWEALTH
Of MASSACHUSETTS
Board of Health, YA 2M0 VT - I ,NIA,
APPLICATION FOR DISPOSAL SYSTLM CONSTRUCTION PERMIT
plication for a Permit to Construct( ) Repair() Upgrade( ) Abandon( ) - W Complete System ❑ Individual Components
Location #51 (A.K.A. #53)
Quartermaster Row
Owner's Name Randy Menard
Map/Parcel# 87-166
Address #51 Quartermaster Row
Lot# 56
Telephone#
Installer's Name E
Designer's Name The BSC Group, Inc.
AddressJ�X
4aain
Address 349 Route 28, Unit D, W. Yarmouth
Telephone# fQ2---ns
S
Telephone# 508-778-8919
Type of Building Residence
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
4
No. of persons
Lot Size 10,006 sq. ft.
Garbage grinder (W?ne
Showers ( ), Cafeteria ( )
Design Flow (min. required) 440 gpd Calculated design flow Design flow provided 459 gpd
Plan: Date 2-14-2013 Number of sheets 1 Revision Date_(i 1 1 r 3
Title Sewage Disposal System Repair 451 Quartermaster Row.
Description of Soil(s) See Plan
Soil Evaluator Form No. Name of Soil Evaluator Kieran Healy Date of Evaluation 2-7-2013
DESCRIPTION OF REPAIRS OR ALTERATIONS
Replace entire system
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 ace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �J
No. _[ FEE �7 , }q�
COMMONWEALTH Of SSAC14USETTS t
Board of Health, \� f FV f
CERTIFICATE Of COMPLIANCE � r3 �,, 7 �c
Description of Work: 0 Individual Component(s) i0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded( ), Abandoned ( )
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by: b7hK
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has been installed in accordance with the provisions o 310 CMR 15.00 (Titl t5) and therapproved design plans/as-built plans relating to
application No. . -- dated�„>. Approved Design Flow t=Q (gpd) /
Installer .� . /�-:,/... , \ ,/ /_._ _ , _l r A-
Desi ner: �_�.- , r> Inspector: i ice`.
g �� _. p L/7 LTi Date: - -
The issuance of this permit shall not be construed as a guaran� a the system will function as designed.
No./�y FEE %T l
COMNIDN I Of MASSACHUSETTS
Board of Health, ,NIA.
DISPOSAL SYSTLM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(X ) Upgrade( ) Abandon( ) an individual sewage disposal system
at- . --r r� - as described in the application for
�--pct. 1P' -il_1 , 1 , - r -
Disposal System Construction Permit No. ,, Z� C 1�77 , dated i f
Provided: Construction shall be completed within thre,6e�&f tl`ie date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadegown, MA Date .Board of Health ��'
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