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/�'15 UCOMMONWEALTH OF MASSACHUSETTS i0
Board of Health, A Z' AD LEW , MA.
APPIFAT®N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradq.('�Abandon( ) - ❑ Complete System Individual Components
Location t
Owner's Name
Map/Parcel# i
Address
Lot#
Telephone#
Installer's Name HAY
Designer's Name
Address -
Address
Telephone# 0� - Z _ t.19
Telephone# 41 j _
Type of Building Lot Size 1 . SbQ sq. ft.
Dwelling - No. of Bedrooms �7i Garbage grinder �J [A
Other - Type of Building No. of persons Showers (&< Cafeterias
Other FixturesC '1��q r�i , hey fN nl [13 JC .5
Design Flow (min. required) gpd Calculated design flow
Plan: Date ce,^^-�a� � 15 NCu�mb� r of shee& C),
Title L
Description of Soils) _
Soil Evaluator Form No.
Name of Soil Evaluator
Design flow provided A 3 � gpd
Revision Date q `hs -15
Date of Evaluation r5k `11-15
DESCRIPTION OF REPAIRS OR ALTERATIONS��\
l
The undersigned es t e b described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of top e e operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 14-14-1,5
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No. V®i t��- 4 �"' ('] FEE t Z-00
o COMMONWEALTH OF MASSACHUSETTS 4 (006
Board of Health, YAV-MQQ1-" , MA. ck
CERTIFICATE Of COMPLIANCE
Description of Work:."Kdividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upg'raded,K, Abandoned ( )
by:
at A V1
� a �_ , .-
has been installed in' acc rdance with the provisions of 3 -W -CMR 15.00 (Title 5) and the auproved design plans/as-built plans relating to
application No. /dated t'� f S . Approved Design Flow 1J (gpd)
i
Installer - - -- ooz-� F,- � _ .-i f s r .it
Designer:"�� kE!::� Inspector: j Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
C, C n '< ta. r., ac c.. pc.c .c _rLr c a� _ ,_oma _.-E:. oo ; cc_b co, root ucc
No. 60ft c -1 C-7-17 35 ClAfZ Hep 15�k� FEE � 0
/,.,- -- � ) COMMONWEALTH Of MASSACHUSETTS dz4kooa
Board of Health, yAwMp Q -N , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission, is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No., dated
as described in the application for
Provided: Construction shall be completed within three -years; o the date of this pertiriil% All local condition must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesl , MA Date % / Board of Health
1,, l ao .sem-,r _ 011- .A•?D
No.:BOHDC-15-1733
� Commonwealth of Massachusetts Fee
$ss.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to: Upgrade-Individual Component(s) '
Location: 199 SOUTH SEA AVE,WEST YARMOUTH,MA 02673 Owner:
STULIC ELAINE
Map/Parcel#: 017.99 6736 28TH AVE N
ST PETERSBURG,FL 33710
Phone:
Septic System Installer Designer
CARMEN E. SHAY CARMEN E. SHAY ENVIRONMENTAL '
P.O. BOX 1576 MASHPEE, MA 02649 P.O. BOX 1576
Phone:
(508)294-7498 MASHPEE, MA 02649
(5081294-7498
Type of Building:Dwelling Lot Size: 10,890.00 S.F. F
Dwelling-No.of Bedrooms:3 Garbage Grinder:
Other Type of Building: No.of persons: Showers: I
Other Fixtures: '
Plan Date:04/24/2015 Number of Sheets:2 Cafeteria:
Tit1e:PLOT PLAN OF PROPOSED SEPTIC SYSTEM 199 SOUTH SEA AVE. Revision Date:04/14/2015
Design Flow(min.required):330 gpd Calculated design flow:330 gpd Design flow provided:333 gpd
Description of Soils:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:02/11/2015
CARMEN E.SHAY,R.S.
� DESCRIPTION OF REPAIRS OR ALTERATIONS:REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,PIPE AND STONE '
LEACH FIELD:30'X 15'X 6°
. The undersigned agrees to instail the above described Individual Sewage Disposal System in accordance with the provisions of TITLE
5 and further agrees not to place in operation until a Certificate of Compliance has been issued by the Board of Health.
i
Signed Date
Inspections
;
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I
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� Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
DISPOSAL SYSTEM CONSTRUCTION PERMIT 555.00
Permission is herby granted to;
SHAY ENVIRONMENTAL, P.O. BOX 1576, MASHPEE, MA 02649
To perform:Upgrade an individual sewage disposal system.
Owner: STULIC ELAINE
6736 28TH AVE N
ST PETERSBURG,FL 33710
Location: 199 SOUTH SEA AVE,WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-1733,Dated:April 15,2015
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, PIPE AND STONE LEACH FIELD:30'X I S'
X 6"
i
2. MFC VARIANCE: 1. GROUNDWATER SEPARATION
3. SLEEVE SEWER LINE OVER WATER LINE CROSSING '
� ,
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 guaraatee that the system witl function as designed.
�
,
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
CERTIFICATE OF COMPLIANCE ass.00
� Description of Work:Individual Component(s)
, The undersigned hereby certify that the Sewage Disposal System; Upgraded
1
,
1, by: SHAY ENVIRONMENTAL
;
� at: 199 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.: BOHDGIS-1733,dated OS/OS/2015.
; Installer: SHAY ENVIRONMENTAL
1
' Address:P.O.BOX 1576 MASHPEE,MA 02649 Inspector:AMY VON HONE,R.S.
i
Designer:CARMEN E. SHAY ENVIRONMENTAL
SERVICES
Conditions
1.REPAIR-EXISTING 1000 GAL SEPTIC TANK,DBOX,PIPE AND STONE LEACH FIELD:-�iA'—
�
�X 6�� /n�=t.✓`S�C.y� �2 � ?C /� )c' � �� S -S i L
2.MFC VARIANCE: 1.GROUNDWATER SEPARATION
3.SLEEVE SEWER LINE OVER WATER LINE CROSSING
i CJ�
jBruce G. Murphy, , .S.,CHO/Amy L.von Hone, R.S.,CHO
�'' Health Director/Assistant Health Director
1'
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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BOH_Disposal_Construction_CofC.rpt
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