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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION /PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade f/jAbandon( - ❑ Complete Systemdividual Components
LocationOwner's
Map/Parcel#
Name
Address
�®
Lot#
Telephone#
Installer's Name
Designer's Name
e
Address
Address
Telephone#a
Telephone# �—gGe
— 3 61
Type of Building 8-1
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size /0 sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures a
Design Flow (min. required) J gpd Calculated design flow 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
Date of Evaluation
The undersigned ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre o to place th t in operatio until a Certificate of Compliance has been issued by the Board of Health.
Signe 4 Date
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No. 6014DC _lS--6673 FEE Q0
COMMONWEALTH Of MASSACHUSETTS CA S14- P= -Cr
Board of Health, ,
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Y, R aired ), Upgraded ( ), Abandoned ( )
by: ��I/��' r -� tR)4tiU S CA VA -3 N Cr—
at
has been installed in11ccor ance wi the ovisions of 310 CMR 15.00 (Title 5) and thea proved design ns as -built Tans r
application No.
, dated %'.�'l %� . Ap rovedpesi n Flow � l f� /�AX^
Installer Nl-4Rf-
Designer: Inspector: 15 Date: 12 6
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. '
C...�_:•C O O OOC __.—; co.,'_.._Jo.; c_c o, c— r— 11-1�- C"__o_C'o,. ,, __.,;o Fo ,. ., (..��io0.. ,, .. n'O C.•., d:,V(.: is
No. 600 DC—/19—O8-k3 m/f2*1vipA FEE $6Y-00
COMMONWEALTH Of MASSACHUSETTS CA.5# ��-
'
Board of Health, O i m o I I -r , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (p Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 9(e!/ GJ637- %,4%-4?0U 1%f- 12-Q • as described in the application for
Disposal System Construction Permit No. �� dated
Provided: Construction shall be completed within t mtgf� t& of this perm 't. All local con J*ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 0 �-�� Board((�of Health
No.:BOHDC-15-0873
� Commonwealth of Massachusetts F�
sss.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Component(s)
LocaHon: 964 WEST YARMOUTH RD,YARMOUTH, MA 02675 Owner:
NARBONNE LEON D 1R
Map/ParCel#: 11525 964 WEST YARMOUTH RD
YARMOUTHPORT,MA 02675
Phone:
Septic System Instailer Designer
MIRANDA'S EAS SURVEY,INC.
476 MAIN STREET HARWICH, MA P.O.BOX ]729
02645 SANDWICH,MA 02563
Phone: (508)888-3619
Type of Building:Dwelling Lot Size:0.23 Acres
Dwelling-No.ot Bedrooms:2 Garbage Grioder.
Other Type of Building: No.otperaoos: S6owers:
Other Fiatures:
Plao Date:Ol/08/2015 Number of Sheets:2 Cafeteria:
TitIe:SEP1IC SYST'EM REPAIR PLAN 964 WEST YARMOUTH ROAD Revision Dah:
Design Flow(mio.required):220 gpd Calculated desigu ilow:220 gpd Design tlow provided:336 gpd
Descriptioo of Soi1s:SEE PLAN
Soil Evaluator Farm No.: Name of Soil Evaluator. Date of Evaluation: 12/23/2014
EDWARD STONE,PLS
DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXIST[NG 1000 GAL SEPTIC TANK,DBOX,24 QUICK4 STANDARD
INFILTRATORS W/OUT STONE:32'X 8.5'X 8" �
, The unde�signetl agrees to fnstall the above tleseribed Indhidual Sewage Dispoaal System in aceordance wkh the p�ovisbns of
TITLE b and furtliar aarees not to olace In ooeration unfil a Certificafe of Comollance has 6ee�iasued bv the Board of Fleakh.
Signed Date ��
Inspections
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
MIRANDA'S EXCAVATING,476 MAIN STREET, HARWICH, MA 02645
To perform: Upgrade an individual sewage disposal system.
Owner: NARBONNE LEON D JR
964 WEST YARMOUTH RD
YARMOUTHPORT,MA 02675
Location:964 WEST YARMOUTH RD,YARMOUTH,MA 02675
Disposal System Construction Permit No.:BOHDC-1S0873,Dated:January 23,2015
Provided: ConsWction shall be completed within six months of the date of this permit. All local condi[ions must be me[.
Conditions
1. REPAIR-EXISTING 1000 GAL SEPTIC Ti1NK, DBOX, 24 QUICK4 STANDARD INFILTRATORS
W/OUT STONE: 32'X 8.5'X 8"
2. PROPERTY LOCATED WITHIN ZONE II-PROPERTY GRANDFATHERED FOR MAXIMLIM 4
BEDROOM WITHAPPROPRIATELY SIZED SEPTIC SYSTEM CURRENT SEPTIC DESIGN FOR A
MAXIMUM 3 BEDROOMTOTAL CAPACITY
� '
Bruce G. Murph ,M , R.S., CHO/Amy L.von Hone, R.S.,CHO
H/e Ith Director/Assistant Health Diredor
1
The issuance of this permit shall not be coostrued as a guarantee t6at the system will tunction as designed.