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6 �� al Board of Health, 1146 ROUTE 28 ,
YARMOUTH MA 02664
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM I1
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Ap icatiori a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - omplete System 0 Individual Components
Location K3 Spfi G=`-4 �
Owner's Name
Map/Parcel#02:18'
Address
Lot#
Telephone# la
Installer's Name CYi "!"7 �,d` '0
Designer's Name �j�'��� ���✓ j��
Address
Address
Telephone# -6"p CF1 —77,5-"'
Telephone# `p
Type of Building 4. ` p Lot'Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow % r Design flow provided �e!�
Plan: Date -> �--z �:;,— - .1-� Number of sheets z Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator Date of Evaluation
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 not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
11
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No.
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FEE S ._
COMMONWEALTH .Of MASSACHUSETTS), - �,�,�� 3 80�
Board of Health, VA.M P Ti H , MA.
Description of Work: 0 Individual Component(s) 1�Complete System
The undersigned hereby certify that the Sewage Disposal Sys4m; Constructed ( ), Repaired ( ),Upgraded �bandoned ( )
by: 0'J ly) � G� C3 �G '' j- J-, fi C
at
has been instaled m accordance wit i tfie provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /� % 6//�' dated " ���%C Approved Design Flow'�(gpd)
Installer V f y_ _ L.__ Ct's20 t✓
Designer: 40-44'40 �,/%% J`'O�l['�,('Inspector:
The issuance of this permit shall not be construed as a''guar
Date:
fitee that the system will function as designed.
No. C — 1 S--3 1315 ' q , LJENc oEJF— FEE i S737-00
COMMONWEALTH LTH ®f MASSACHUSETTS
Board of Health, Yi3rf:tAA7rI +
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(/,Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 6�OG%` c� ��y as described in the application for
Disposal System Construction Permit No. ��� ✓6C� , dated
Provided: Construction shall be completed within t1tree-VMs of the date of this permit. 1 ocal conditions. ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co.Charlestown, MAS Date �� Board of Hea�h
A f� e� moi/ A� ��-�/ 2 1�--4G k',ev `g4j
No.:BOHDC-15-3135
° � Commonwealth of Massachusetts Fee
$55.00 '
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT '
Application for a Permit to:Upgrade-Complete System
Location: 63 SOUTH SEA AVE,WEST YARMOUTH, MA 02673 Owner:
HOLDENJOANNE
Map/Parcel#: 023.181 RAPP ROBERT
106 FORD RD
WOODBRIDGE,CT 06525
Phone:
Septic System Installer Designer
JIM LEBOEUF SEPTIC DAVID B.MASON.R.S.
55 BODICK ROAD HYANNIS, MA 02601 4 GLACIER PATH
Phone: EAST SANDWICH,MA 02573
508-833-2177 i
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Type of Building:Dwelling Lot Size: 10,890.00 Acres ;
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers:
Other Fixtures:
Plan Date:07/27/2015 Number of Sheets: 1 Cafeteria•
Tit1e:SITE AND SEWAGE PLAN 63 SOTH SEA AVENUE Revision Date:
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:331.52 gpd
Description of Soils:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:07/15/2015
� • DAVID B.MASON,R.S.
DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,45'X
10'X 6"LEACH FIELD
� The undersigned agrees to install the above described Individual Sewage Disposal System in accordance wkh the provisions of
TITLE 5 and further aarees not to ulace in ooeration until a Certificate of Comoliance has been issued 6v the Board of Heakh.
Signed Date
Inspections
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� � Commonwealth of Massachusetts
� � Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT $55.00
Permission is hereby granted to;
JIM LEBOEUF SEPTIC SERVICE, 55 BODICK ROAD, HYANNIS, MA 02601
To perform: Upgrade an individual sewage disposal system.
Owner: HOLDEN JOANNE
RAPP ROBERT
106 FORD RD
WOODBRIDGE,CT 06525
Location: 63 SOUTH SEA AVE, WEST YARMOUTH, MA 02673
Disposal System Construction Permit No.: BOHDC-15-3135 ,Dated: August 11,2015 '
Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
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CONDITIONS:
1. SEPTIC DISPOSAL- REPAIR- PROPOSED 1500 GAL SEPTIC TANK, DBOX,45'X 10'X 6"
LEACH FIELD
2. BOH TO INSPECT SOIL REMOVAL
3. PLUMBING PERMIT REQUIRED
4. MFC VARIANCES APPROVALS: a. GROUNDWATER ADJUSTMENT b. SETBACKS
�
. Bruce G. Mur PH, R.S., CHO/Amy L. von Hone, R.S., CHO
ealth Director/Assistant Health Director �
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The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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� Commonwealth of Massachusetts
;
; Board of Health, Yarmouth, MA Fee
�
� CERTIFICATE OF COMPLIANCE ass.00
Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:JIM LEBOEUF SEPTIC SERVICE
at:63 SOUTH SEA AVE,WEST YARMOUTH,MA 02673
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-15-3135,dated 08/24/2015.
Installer:JIM LEBOEUF SEPTIC SERVICE
Address:55 BODICK ROAD HYANNIS,MA 02601 Inspector:AMY VON HONE,R.S.
Designer:DAVID B.MASON,R.S.
�
Bruce G. Murphy P , R. ., CHO/Amy L.von Ho e, R.S.,CHO
Health Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarant that the system will function as designed.
BOH_Disposal_Construction_CofC.rpt ?
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