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No. 80H DC45 510 /! 8LD7X --J5_- 00g17q FEE k-y:cz
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, 15r2ititlE,`Z'F 1 , MA• — a� 5 4` _14 odd
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION/ PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade.(/Abandon( ) - Ll Complete System -CI Individual Components
Location '7Z
Owner's Name
Map/Parcel# Ile p,�f��5�
Address ZZ s ,�p�S
Lot#
Telephone# Sd -�(Z - 3 3 y
Installer's Name ���� ��� �/
Designer's Name S
Address ��l> �f� /�Of✓. 5��
Address �� il' ���.3 �/'f��,�G-�/✓��
Telephone#
Telephone#
Type of Building %i'��� D� ��� -� L IV d S 60k --50V- S`SYS Lot Size 2 d -_$Z sq. ft.
Dwelling - No. of Bedrooms y Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 1-1gil gpd Calculated design flow _ L%F % Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation // -/Z :��
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 7A - Date
Inspections
No. `bomb C"
f 40 -7
Description of Work:
The undersigned hei
by:
at
has been installed n
application NNc /
Installer &zt.,4
Ile, Ar % FEE O �
COMMONWEALTH OF MASSACHUSETTS lttl Le a��
_Y -t MA. a
Board of Health, ,
CERTIFICATE Of COMPLIANCE MICAl 5,
❑ Individual Components) ❑ Complete System
)y certify that the Sewage Disposal System; Constructed ( ), Repaired (-) , jUpgraded
c6rdal�t'te wit the provisions of 319 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
�_(o 2, dated 4 -2,-'01 / Approved Design Flow (gpd)
), Abandoned ( )
ry/
)fVA.4j SM
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
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No. i%*i ✓�JC %(o�/ ce_NTV12Vd��j U L 7— FEEJ J . Q0
COMMONWEALTH Of MASSACHUSETTS ckw S
Board of Health, yAR�o VTU , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at�, .5'l�"lf '.c� as described in the application for
Disposal System Construction Permit No. 7 , datedy
6 o . z , -/(-q/
Provided: Construction shall be completed within rlirPP vaears of the date of this permit. All o al conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown. MA Date ^Boar of H91th
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� No.:BOHDGIS-1691
' Commonwealth of Massachusetts Fee
$55.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to:Upgrade-Individual Component(s)
Location: 72 SEMINOLE DR,YARMOUTH, MA 02675 Owner:
� PELLAGRINI ALBERT J
� Map/Parcel#: 116.97 PELLAGRINI THELMA C
P O BOX 276
{ YARMOUTH PORT,MA 02675
i Phone:
�
� Septic System Installer Designer
i
; CENTURY VAULT CO., BASS RIVER ENGINEERING
i 918 MAIN STREET WEST P.O.BOX 1163
! BARNSTABLE, MA 02668 EAST DENNIS,MA 02641
; Phone: (5081385-3426
� Type of Building:Dwelling Lot Size: 12,632.40 Acres
Dwelling-No.of Bedrooms:4 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
i
�� Plan Date: 11/13/2014 Number of Sheets: 1 Cafeteria•
Tit1e:SITE PLAN 72 SEMINOLE DRIVE Revision Date:04/23/2015
Design Flow(min.required):440 gpd Calcuiated design flow:440 gpd Design flow provided:487 gpd
Description of Soi1s:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation: 11/12/2014
T
• DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,35 INFILTRATOR QUICK 4
STANDARD LINITS W/OUT STONE:30'X 1S X 8"
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
� TITLE 5 and further aarees not to olace in ooeration until a Certificate of Comoliance has been issued bv the Board of Health.
Signed Date
Inspections
' Commonwealth of Massachusetts
.
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is herby granted to;
CENTURY VAULT CO., INC., 918 MAIN STREET,WEST BARNSTABLE, MA 02668
To perform:Upgrade an individual sewage disposal system.
� Owner: PELLAGRINI ALBERT J
PELLAGRINI THELMA C
P O BOX 276
' YARMOUTH PORT,MA 02675
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' Location:72 SEMINOLE DR,YARMOUTH,MA 02675
�
� Disposal System Construction Permit No.: BOHDC-15-1691 ,Dated:April 24,2015
1 Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
Conditions
1. REPAIR-EXISTING 1000 GAL SEPTIC TANK, DBOX, 35 INFILTRATOR QUICK 4 STANDARD
� UNITS W/OUT STONE: 30'X I S'X 8"
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i 2. MFC VARIANCES: 1. SETBACK TO FOUNDATION 2. WETLAND SETBACK 3. SETBACK TO
� DRAINAGE EASEMENT
� �
� . Br
i uce G. rphy, MPH, R.S., CHO/Amy L.von Hone, R.S., CHO
Health Director/Assistant Health Director
I
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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