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COMM®N LTH OF MASS C14USETTS
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Board of Health, Y�4f=M 011n4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( pgr( adeO Abandon - LJ Complete System Z dividual Components
Location
Owner's Name
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
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Designer's Name
Address
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Address
Telephone#
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Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
..,7.—
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
REPAIRS OR ALTERATIONS
0
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
A,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to ace the tem ' tion until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 5-1 �s�i
No. ® C ' � �' y { FEE
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Board of Health, Y 494140 UTH
CERTIFICATE Of COMPLIANCE
Description of Work:,.l.d�di idual Component(s) ❑ Complete System
The undersigned hereby,�ertifyfthat the Sewage Disposal System; Constructed ( ), Repaired (graded ( ), Abandoned ( )
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has been install withthc�"prd �sions of 310 15.00 (Title�nd the approved design plans/as-built plans relating to
application No. dated Approved Design Flow -:?'_-)- Q (gpd)
Installer
Designer:- Inspector: Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
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No. -6041K-152-0-5-7 FEE $ 2Z,00
/ C®MMONWEAETII Of MASSACHUSETTS
Board of Health, _ %1 0 u , MA.
DISPOSAL SYSTLM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair(—,) --Upgrade ( ) Abandon ( ) an individual sewage disposal system
0 t4W as described in the application for
Disposal,,System Construction Permit No.
Provided: Construction shall be
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date
wi
t, dated a= 2'3
gee -.ass of the date of this permit. All local conditions must be met.
f'.oard of Health
No.:BOHDC-15-1457
Commonwealth of Massachusetts F�
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Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Application for a Permit to:Repair-minor-Individual Component(s)
Location: 12 ST ANDREWS WAY, SOUTH YARMOUTH, MA 02664 Owner:
JACKSON WILLIAM
Map/Parcel#: 080.97 JACKSON MARY LOU
32 BERKSHIRE ST
NORFOLK,MA 02056
Phone:
Septic System Installer Designer
ELLIS BROTHERS
23 ENTERPRISE ROAD
YARMOUTHPORT, MA 02675
Phone:
Type of Building:Dwelling Lot Siu:026 Acres
Dwelting-Na of Bedrooms:2 � Garbage Grinder: _
Other Type of Building: No,of persons: Showers:
Other Fiatures:
Plan Date: Number of Shcets:
Cafehria:
Title: Revision Date:
Desigo Flow(mio.required):220 gpd Calculated desigo flow:220 gpd Desigo flow provided: gpd
DescripHon of Soils: '�..
Soil Evaluator Form No.: Name of Soil Evaluator: Date otEvaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:MINOR REPAIR-SEAL LEAKING SEPTIC TANK !
The unde�signed agrees W Insfall the above deseribed IndNidual Sewage Disposal3ystem in aecordance wkhlhe proviafons of I,
T1TLE 5 and furfher aareea not to otace In ooaration untll a Certifieate of Comollanee has 6een issued bv the Bosrd of Heakh. �'�.
Signed pay� I
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FBa
DISPOSAL SYSTEM CONSTRUCTION PERMIT ass.00
Permission is herby granted to;
ELLIS BROTHERS CONSTRUCTION,23 ENTERPRISE ROAD,YARMOUTHPORT, MA 02675 �
To perform:Repair-mi�or an individual sewage disposal system.
Owner: JACKSON WILLIAM
7ACKSON MARY LOU
32 BERKSHIRE ST
NORFOLK,MA 02056
LocaYion: 12 ST ANDREWS WAY, SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDC-1S1457,Dated: March 23,2015
Provided: Cons[ruction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions
1. MINOR REPAIR-SEAL LEAKING SEPTIC TA1VK
��c>Cv G�o
Bruce G. Murplfy, MPH, R.S., CHO/Amy L.von Hone, R.S.,CHO
�' Health Director/Assistant Health Diredor
The issuance of this permit shall not be construed as a guarantee that the system will FuoMion as designed.
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; Commonwealth of Massachusetts
� Board of Health, Yarmouth, MA F�
, CERTIFICATE OF COMPLIANCE sss.00
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iDescription of Work:Individual Compoaent(s)
� The undersigned hereby certify that the Sewage Disposal System;Repair-minor
by:ELLIS BROTHERS CONSTRUCTION
� at: 12 ST ANDREWS WAY,SOUTH YARMOUTH,MA 02664
Has been installed in accordance with the provisions of 3]0 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDC-15-1457,dated 03/24/2015.
Installer:ELLIS BROTHERS CONSTRUCTION
Address:23 EN7'ERPRISE ROAD YARMOUTHPORT, Inspector:AMY VON HONE,R.S.
MA 02675
Designer:
Conditions
1.MINOR REPAIR-SEAL LEAKING SEPTIC TANK
Bruce G. Murphy, H .S., CHO/Amy L.von Hone, R.S., CHO
Health Director I Assistant Health Director
The issuance of this permit shall not be construed as a guarantee t t the system will function as desigaed.
BOH_Disposal_Construction CofC.rpt