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No.
MN
Owner's Name
'FEE
Map/Parcel# Z& --
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Address 7floocsle,
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Board of Health, YAeK0 0-M , MA. �6,7y- %-12 "
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIIT
A plication for a Permit to Construct( ) Repair( ) Upgrade (/Abandon( ) - ❑ Complete System "dividual Components
ocation hogs—e— Vnd"
Owner's Name
5
Map/Parcel# Z& --
Address 7floocsle,
Av
Lot#
Telephone#
Installer's Name 1
Designer's Name
Gko yktR-(21qT&A RS
AddressS j
C
Address
Telephone# _
Telephone#
' — %_f
Type of Building 1251 �G�'"' G� Lot Size .�f sq. ft.
Dwelling - No. of Bedrooms E iGS , C Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3-50 gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided 3 5`3 gpd
Revision Date
Date of Evaluation
5
The undersigned agye§L to install the a ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to 'o pla in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed '_ Date .11-15
(Inspections
No. iT�'•» t "'�J, ,� !ir�i,'FEE 7�:7 .•. /171
f — _
COMMONWEALTH Of MIASWH USETTS Wil_
Board of Health, 0 UT -A , MA.
W-VICATE OF COMPLIANCE
Description of Work-„drfidividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage' Disposal System; Constructed ( ), Repaired (4,upgraded ( ), Abandoned O j�
by:%!�'t'�c
at �e {`, i� r �'r d
has been instali"ed n accord nce with therovisions_of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. f _, dated, 4-, ..;Approved Design Flow -3 (gpd) �!
.Installer fie', � A) 14 AS �.. � � . ✓i �,� � /��=C'C�L''��
Designer: C Ct=rl &r7Al1-°'-P)N X5 Inspector: <ty Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
O fJO11 00 1,10 7000^J.^,r,000'^0.
No.OICy�..��� fr• d�}5 FEE`�.5,..
COMMONWEALTH Of MASSACHUSETTS `.�. 3 (vt-77
Board of Health, ) A$M► 0 OT”
DISPOS A ]L�.,Y-STCONSTRUCTION PERMIT
.,..:
Permission is hereby granted to; Construct( Repair(1) Upgraded Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. �S� , dated 1�
Provided: Construction shall be completed within three sr - the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 6 -, / Board of Health % �✓ (iJ J
No.: BOHDC-15-2154
. Commonwealth of Massachusetts Fee
ass.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
Application for a Permit to: Upgrade-Individual Component(s)
Location:4 HORSE POND RD,WEST YARMOUTH, MA 02673 Owner:
ANAGNOS STEPHEN A
Map/Parcel#: 046.59 4 HORSE POND RD
WEST YARMOUTH,MA 02673
Phone:
Septic System Installer Designer
RODNEY FISHER GLEN HARRINGTON,R.S.
440 MAIN STREET HARWICH, MA 9 LEDA ROSE LANE
02645 MARSTONS MILLS,MA 02648
Phone: (7741238-1813
Type of Building:Dwelling Lot Size:21,780.00 Acres
DwelGng-No.of Bedrooms:2 Garbage Grinder.
Other Type of Building: No.of persons: Showers:
Other Fiatures:
Plan Date:04/28/2015 Number of Sheets: 1 Cafeteria:
Tit1e:PROPOSED SEP1'[C SYSTEM REPAIR 4 HORSE POND ROAD Revision Date:
Desigo Flow(min.required):220 gpd Calculated design flow:220 gpd Design flow provided:353 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator. Date of Evaluation:04/23/2015 �
GLEN HARRINGTON,R.S.
� DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXISTING]000 GAL SEPTIC TANK,DBOX,2-500 GAL PRECAST
CIIAMBERS W/4'STOIVE:25'X 13'X 2'
The undersigned agrees to install the above tleseribetl Indivitlual Sewage D�posal System in accordance with the provisions of
� TITLE 5 and further aarees not tn olace in ooeration until a Cerfifitate of Comoliance has heen Issued W the Boartl of Health.
Signed Date
Inspections
Commonwealth of Massachusetts
' Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT sss.00
Permission is herby granted to;
RODNEY FISHER SEPTIC SERVICE,440 MAIN STREET, HARVNCH, MA 02645
To perform:Upgrade an individual sewage disposal system.
Owner: ANAGNOS STEP}IEN A
4 HORSE POND RD
WEST YARMOUTH,MA 02673
Location:4 HORSE POND RD,WEST YARMOUTH,MA 02673
Disposal System Consuuction Permit No.: BOHDGIS-2154,Dated: May 22,2015
Provided: Construction shall be completed wi[hin six months of the date of[his permit. All local wndi[ions must be met.
Conditions
1. REPAIR-EXISTING 1000 GAL SEPTIC TANK, DBOX, 2-500 GAL PRECAST CHAMBERS W/4'
STONE:25'X 13'X 2'
ZONE II MAXIMUM 2 BEDROOMS
��/
Bruce G. urphy,MPH, R.S., CHO/Am L.von Hone, R.S., CHO
Health Director/Assistant Health Diredor
The issuance of this permit shall not be construed as a guarantee t6at the system will funMion as designed.