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COMMONWEALTH Of MASSACHUSETTS
Board of Health, '_ia1�0,N , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
Application for a Permit to Construct(.,) Repair( ) Upgrade(04 Abandon( ) - ❑ Complete System Ajndividual Components
0 `L ki n e 1 XA
Location 5-
Owner's Name
Map/Parcel# k 0 -7 - 43
Address 5.0 r nt QZd qr M cry Pyr 6 Z E _S^
Lot# Lo+ 3o Pto," Q 1/1, 4&7 Fy 4(
Telephone# 56 - 3Cz-7- 3 a _
Installer's Name D �?�� �� \r`C
Designer's Name e -f EelKRee
Address e d.lGox vqs ��eh ��la j \R Q 2to3 z-
Address IL
Telephone# 400 = J t 59
Telephone# ,,76 7-4 7 -T -5 3 t 3
Type of Building P-.eS Lot Size 14 e (,�3 sq. ft.
Dwelling - No. of Bedrooms y Garbage grinder ( )
Other - Type of Building N JeN No. of persons Showers ( ), Cafeteria ( )
Other Fixtures N I I-)
Design Flow (min. required) `�y b gpd Calculated design flow TAQ Design flow provided 'A 5A -'A gpd
Plan: Date 361 tS Number of sheets 'Z- Revision Date
Title Pnsk�i+�v,lt dti �ec�r'e. .h St7 (� h ; 6 � �'tAA
Description ofSoil (s) d-!oF�� by -1`1 A: L5 3: CS. '3C"- It $r 5,
Soil Evaluator Form No. Name of Soil Evaluator 3?ekirALG Date of Evaluation 1 Z \7 t
.5v-h--t�Z
DESCRIPTION OF REPAIRS OR ALTERATIONS F—.eAe zi i -, -y . \l 3 - SV
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections 6— —/ U401./ �&- 5 Z 6
COMMONWEALTH OF MASSACHUSETTS a�
Board of Health,
CERTIFICATE Of COMPLIANCE 06`'
Description of Work: 0Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded..r✓}�bandoned ( )
by: J>. A . -' czo uU h3 i t l c-
at 50 "INI P -PAD
i:�ir.. G- i _
has been installed in`P, ance wce.ith
application No. Z4 -00 rr�1 datE
Installer T006LA5 A ` Gi1-Q
of 310 CMR 15.00 (Title 5) and the ap�prpved design plans/as-built plans relating to
Approved Design Flow `� 7 (gpd)
Designer: ft�91�/ !�Vf*/-0SInspector: _/`�`! �Yt/i. Date:
The issuance of this permit shall not be construed as a guarantrA/hat the system will function as designed.
No. Q .Dc— 15-2-m360 �. fJi�oLt)N FEE °$ 5. bd
COMMONWEALTH OF MASSACHUSETTS C-42-4'
Board of Health,a rM w t_.(� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Permission is hereby granted to; Construct( ) Repair( ) Upgrade4_-)--Abandon( Abandon( ) an individual sewage disposal system
at 50 V" (tic P -OA -0 as described in he application for
Disposal System Construction Permit No. /5-- / , dated
/,-b i t i.5' --2-,(_G
Provided: Construction shall be completed within tIIIre-9ems of the date of this permit, All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date y Board of Hea h `s%i `-
No.: BOHDGIS-2360
� Commonwealth of Massachusetts Fee
555.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Compouent(s)
Location: 50 RHINE RD,YARMOUTH, MA 02675 Owner:
DAVIS TODD W
Map/Parcel#: 107.43 DAVIS MICHELLE L
50 RIIINE ROAD
YARMOUTH PORT,MA 02675
Phone:
Septic System Installer Designer
DOUGLAS A.BROWN ENGINEERING WORKS.INC.
P.O. BOX 145 CENTERVILLE, MA 12 WEST CROSSFIELD RD
02632 FORESTDALE,MA 02644
Phone: (508�77-5313
Type of Building:Dwelling Lot Size: 14,810.00 Acres
Dwelling-No.of Bedrooms:4 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fictures:
Plan Date:Ol/30/20I5 Number of Sheets:2 Cafeteria:
Tit1e:PROPOSED SEPTTC SYS1'EM UPGRADE PLAN 50 RIIlNE ROAD Revision Date:
Desigo Flow(min.required):440 gpd Calculated design flow:440 gpd Design tlow provided:454.4 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: 12/17/20t4
PETER MCENTEE,PE
DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,3-500 GAL PRECAST
CHAMBERS W/4'STONE:33.5'X 12.8'X 2'
� The undersigned agrees to insfall the above described Indlvidual Sewage Disposal Syatem in aecordance with the provisions of
717LE 5 and further aarees not to olace in ooeration unUl a CertlFlcate of Comoliance has 6een issued hv the Board of Flealth.
Signed Date
Inspections
: Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
DOUGLAS A. BROWN INC., P.O. BOX 145, CENTERVILLE, MA 02632
To perform: Upgrade an individual sewage disposal system.
Owner: DAVIS TODD W
DAVIS MICHELLE L
50 RIIINE ROAD
YARMOUTH PORT,MA 02675
Location: 50 RHINE RD,YARMOUTH,MA 02675
Disposal System Construction Permit No.: BOHDGIS-2360,Dated:June 08,2015
Provided:Construction shall be completed within six mon[hs of the date of this permit. All local conditions mus[be met.
Conditions
1. REPAIR-EXlSTING 1000 GAL SEPTIC TANK, DBOX, 3-500 GAL PRECAST CHAMBERS W/4'
STONE. 33. S'X 12.8'X 2'
�V
Bruce G. rphy,MPH, R.S., CHO!Amy L.von 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.
i
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA FeB
CERTIFICATE OF COMPLIANCE 555.00
Description of Work: Individual Component(s)
The undersigned hereby cer[ify that the Sewage Disposal System; Upgraded
by:DOUGLAS A.BROWN INC.
at 50 RHINE RD,YARMOUTH,MA 02675
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-15-2360,dated 07/Ol/2015.
Installer:DOUGLAS A.BROWN INC.
Address:P.O.BOX 145 CENTERVILLE,MA 02632 Inspector:AMY VON HONE,R.S.
Designer:ENGINEERING WORKS,INC.
Conditions
1.REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,3-500 GAL PRECAST CHAMBERS
W/4' STONE: 33.5' X 12.8' X 2' �A,
�(�C
Bruce G. Mu y, PH, 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 function as designed.
BOH_Disposal_Construction_CofC.rpt