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FEE
COMMONWEALT14 OF MASSAC14USETTS
Board of Health,ykamooTx
If
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - Ll Complete System U Individual Components
Location 10
Owner's Name Zu a
Map/Parcel#
Address ZZ wz&hja� go
Lot#
Telephone#
Installer's Name
Designer's Name
Address .5r
Address
Telephone* Z
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.
— gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder
Showers ( ), Cafeteria
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS o c 7 S k CIV17)
,_IZ40 -2- tev dk--
The undersigned agrees to install the ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t ce the em in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed OF V, Date 7— /T—
Inspections
3 3,1 _I'D "M
No. &pj47c- 19424,3 FEE t55, 00
COMMONWEALTH OF MASSACHUSETTS
Board of Health, . S�f
93M h ( , AL4.
CERTIFICATE Of COMPLIANCE �f7
Description of Work: Ll Individual Component(s) - El Complete System
The undersigned h by certify tha Sewage Disposal System; Constructed Repaired (graded ),Abandoned(
by:
smy# cc_
at -71
has been inWecfi'fi"a-ccoi'da-n"c6Xth the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.:2 :Z dated Approved Design Flow (gpd)
Installer a- nb k)
Designer: Inspector: 'IKZ/6 V&&" Date:
The issuance of this permit shall not be construed as a guarardee that the system will function as designed.
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No. E�Oqpc P, FEE 55 00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, VW4 0 M4
DISPOSAL SYSTEM CO
Permission is hereby granted to; Construct( ) Repair( TRUCTION PERMIT Upgrade( Abandon( )an individual sewage disposal system
at 1Zas described in the application for
_V
Disposal System Construction Permit No. dated
Provided: Construction shall be completed
or,p eted within three years of the date of this permit.--rAll local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date :3 "Board of Health
No.:BOHDC-IS-1243
Commonwealth of Massachusetts F�
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Repair-minor-Individual Compooent(s)
Location: 71 WITCHWOOD RD,SOUTH YARMOUTH, MA 02664 Owner: �
LAWRENCE,DONALD R
Map/Parcel#: 068.86 LAWRENCE,MARCIA C
71 WITCHN'OOD RD
SO YARMOUTH,MA 02664
Phone:
Septic System Installer Designer
RODNEY FISHER
440 MAIN STREET HARWICH, MA .
02645
Phone:
Type of Building:Dwelling Lot Size:026 Acres
Dwelling-No.of Bedrooms:4 Garbage Grinder:
Other Type of Building: No.ot persons: Showers:
Other Fietures:
Plan Dah: Number of Sheets:
Cafeteria:
Title: Revision Date:
Design Flow(min.required):440 gpd Calculated design flow:440 gpd� Design ilow provided: gpd
Description ot Soils:
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:
DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-REPLACE DBOX FOR 1987 TITLE 5 SYSTEM(2002 TTTLE 5 SYSTEM
OK)
The unde�signetl agrees to install Me above described Individual Sewage Dlaposal Syatem in accordance wkh the provisiona of
TITLE 5 anA furfher aarees not to olace in ooeretion until a Certificate of Comolianee has been issued W the Board of HeaMh.
Signed Date
Inspections
i � '
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FeB
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is herby granted to;
RODNEY FISHER SEPTIC SERVICE,440 MAIN STREET, HARWICH, MA 02645
To perform:Repair-minor an individual sewage disposal system.
Owner: LAWRENCE,DONALD R
LAWRENCE,MARCIA C
71 WITCHWOODRD
SO YARMOUTH,MA 02664
Location: 71 WITCHWOOD RD, SOUTH YARMOUTH,MA 02664
Disposal System Construction Permit No.: BOHDG1S1243,Dated:Marc6 04,2015
Provided: Construc[ion shall be completed wi[hin six months of the date of[his permit. All local conditions must be met.
Conditions
1. REPAIR-REPLACE DBOX FOR 1987 TTILE 5 SYSTEM(2002 TITLE.5 SYSTEM OK)
Bruce G. rph , PH, R.S., CHO/Amy L. van 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.
T �
Commonwealth of Massachusetts
Board of Health, Yarmauth, MA Fee
I� CERTIFICATE OF COMPLIANCE sss.00
I
�
� DescripEiott of Work:Individual Component{s)
The undersigned hereby certify that the Sewage Disposal System; Repairvminor
by:RODNEY FISHER SEPTIC SERVICE
iI at:71 WITCHWOOD RD,SOUTH YARMOUTH,MA 02664
� Has been installed in acwrdance with the provisions of 310 CMR 15.00(Title 5}and the approved
design plans or as-bnilt pians relaring to appiication No.: Bt?ADC-1Si243,dated 03JQ5t2015.
Installer.RODNEY FISHF,R 3EPTIC 3ERVECE
� Address:440 MAIN STREET I-iARWICH,MA 02645 Inspector:AMY VON HONE,R.S.
Designer:
Conditions
1.RF.PAIR-BEPLACE DBOX FOR 1987 TITLE 5 SYST Q02 TITLE YSTEM OK)
� �
Bru G. urphy,MPH,R.S.,GHO/Amy L.von Hone, R.S.,CHO
Health Director/Assistant Health Director
The issuance of this permit shall not be conetrued as a guarantee that the system will function as designed.
BdH_Disposal_ConsUvdion_CofC.rpt