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Board of Health, YC]�O U % 14
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
E".1:13
Apj lication for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ❑ Complete System dividual Components
cation S'"oAT 2j- L4 - 'V
Type of Building AQ:�, P�g�%,co. Lot Size sq. ft.
Dwelling - No. of Bedrooms oyie-, Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
gpd
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 th syst in in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date i, J
Inspections
No. F -104K ",'db(I FEE .+
% - 7 C®�' MON L114 OF SSACHU. SETTS � 4 9 -/i5'
Board of Health, Y,4/ZM0QT-N , AL4.
CERTIFICATE Of COMPLIANCE /1XPf 4W,7411V
Description of Work: Ltl Individual Component(s) ❑ Complete System �% �" p �d �44
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (0/Upgraded ( ), Abandoned ( )
by:" -t F
at D V f t. ' i < , e,—
has been installed in actor ante tinth t e ovisions of l CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /'``-Z dated . Approved Design.Flow W" (gpd)
Installer _ -- _s1 _ c
Designer: ,) 1 i Inspector L+ Vim` Date:
The issuance of this permit shall not be construed as a guarant a that the system will function as designed.
No. oWC_ "N 4) W k , �.._ � . FEE
C( N1MON4I.TR Of MASSACHUSETTS c4c*1 o
Board of Health, YA IZM0 tj174
DISPOSAL SYSTEM 'CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(,,,,"Upgrade( ) Abandon( ) an' individual sewage disposal system
at .�OS a , �43 as described in the application for
Disposal System Construction Permit No
Provided: Construction shall be completed within tl� -of
'J� 'Ste of this permits All local condition must be met.
1�.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Date Board of Health"
Owner's Name
Map/Parcel# _. j, j G
Address s -a 3 % &' W
Lot#
Telephone# o �J/� j
45 3 PJ
Installer's Name
Designer's Name
Address ,>-T&
Address
Telephone# jft-8 %9 d
Telephone#
Type of Building AQ:�, P�g�%,co. Lot Size sq. ft.
Dwelling - No. of Bedrooms oyie-, Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
gpd
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 th syst in in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date i, J
Inspections
No. F -104K ",'db(I FEE .+
% - 7 C®�' MON L114 OF SSACHU. SETTS � 4 9 -/i5'
Board of Health, Y,4/ZM0QT-N , AL4.
CERTIFICATE Of COMPLIANCE /1XPf 4W,7411V
Description of Work: Ltl Individual Component(s) ❑ Complete System �% �" p �d �44
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (0/Upgraded ( ), Abandoned ( )
by:" -t F
at D V f t. ' i < , e,—
has been installed in actor ante tinth t e ovisions of l CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /'``-Z dated . Approved Design.Flow W" (gpd)
Installer _ -- _s1 _ c
Designer: ,) 1 i Inspector L+ Vim` Date:
The issuance of this permit shall not be construed as a guarant a that the system will function as designed.
No. oWC_ "N 4) W k , �.._ � . FEE
C( N1MON4I.TR Of MASSACHUSETTS c4c*1 o
Board of Health, YA IZM0 tj174
DISPOSAL SYSTEM 'CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(,,,,"Upgrade( ) Abandon( ) an' individual sewage disposal system
at .�OS a , �43 as described in the application for
Disposal System Construction Permit No
Provided: Construction shall be completed within tl� -of
'J� 'Ste of this permits All local condition must be met.
1�.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Date Board of Health"
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
CERTIFICATE OF COMPLIANCE 555.00
Description of Work: Individual Component(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:B.C.K.GENERAL CONTRACTOR
at: 503 ROUTE 28,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.: BOHDC-140611,dated 12/12/2014.
Installer:B.C.K.GENERAI,CONTRACTOR
Address:97 TOWN BROOK ROAD WEST Inspector.AMY VON HONE,R.S.
YARMOUTH,MA 02673
Designer:
Conditions
1.REPLACE H-20 DBOX,NEW PIPING FROM EXISTING SEPTIC TANK TO DBOX AND
DBOX TO EXISTING LEACH PIT
Bruce G hy,MPH, R.S., /Amy L.von Hone, R.S., CHO
Health Director/Assistant Health Director
T6e issuance of this permit shall not be construed as a guarantee that the system will function as designed.
80 H_Disposal_Construdion_CofC.rpt