App-Permit-ComplianceNo. �d C S � � � WD -112--1 G ®t✓00 67-6 FEE 1z z7,00
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COMMONWEALTH LTH ®f MASSACHUSETTS
Board of Health, l ASM 0 OT14, MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repai Upgrade( ) Abandon( - �omplete System El Components
Location
Owner's Name
Map/Parcel#Address
0!;;
Lot#
Telephone#
Installer's Name A Kcr L
Designer's Name polu^Ca 4--A- ` T
AddressFG Mi�
Address y' .7 ti * *- L `� o
Telephone# 7 7y_ ' -4 %* °
Telephone#
Type of Building Well, La � Lotsize + 44y os sq. ft.
Dwelling - No. of Bedrooms %/►1Y'a:. Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) �� gpd Calculated design flow SVV Design flow provided y gpd
Plan: Date 7/21/A i Number of sheets ' Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS y
A SI -11
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 Co pli a has been issued by the Board of Health.
Signed Date d� _%�_
Inspections
No. i' 1011A Dc A
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COM MONWEAI,TII Of MASSACHUSETTS
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Board of Health YA 2M d U TIA MA.
CERTIFICATE OF COMPLIANCE
Description of Work: D Individual Component(s)-EMomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(; Abandoned ( )
by: jZ, �°, e r �,, 9 �ri n r✓ice tYy�
at ` i tri �/C'Yora 1'��t�
has been installed in
application No.
Installer A. kJ
l//'�/ r y, -- ; "6 i
ccor7dance with the r -6sions of 310 CMR 15.00 (Title 5)
/! % , dated _�-'`4 Approved Design Flow
design plans/as-built plans relating to
Designer: Del iy^ cao r q1n t / 7 Inspector: �' �. �; G y,. << Date:
The issuance of this permit shall not be construed as a guar��t the system will function as designed.
7 / COMMONWEALT14 Of M ASSAC14USETTS
Board of Health, YAt ZM O UT 4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
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Permission is hereby granted to; Construct( ) Repair" Upgrade( ) Abandon( ) an individual sewage disposal system
at %C'+�+iC�� ���c'r_ as described in the application for
Disposal System Construction Permit No. I , dated�'Z -rC
Provided: Construction shall be completed within tkree years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Z71-1 Boa rdfo Health
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Commonwealth of Massachusetts k
Board of Health, Yarmouth, MA Fee �
CERTIFICATE OF COMPLIANCE 555.00 C
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Description of Work:Complete System
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:RIKER LAND CONSTRUCTION '
at:4 TEMPLETON PL,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-15-3187,dated 09/02/2015.
Installer:RIKER LAND CONSTRUCTION
Address:P.O.BOX 726 SOUTH YARMOUTH,MA Inspector:AMY VON HONE,R.S.
02664
Designer:DOWN CAPE ENGINEERING,INC.
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Bruce G. Mu hy,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 guararttee that the system will function as designed.
BO H_Disposal_Construction_CofC.rpt
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No.:BOHDGIS-3187
° Commonwealth of Massachusetts Fee '
ass.00 `
Board of Health, Yarmouth, MA ;
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT �
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Application for a Permit to:Upgrade-Complete System �
Location:4 TEMPLETON PL,WEST YARMOUTH, MA 02673 Owner:
PANKRATZ DAVID J
Map/Parcel#: 087.6 PANKRATZ ANDREA
P O BOX 385
REHOBOTH,MA 02769
Phone:
Septic System Installer Designer
RIKER LAND DOWN CAPE ENGINEERING,INC.
P.O. BOX 726 SOUTH YARMOUTH, MA 939 ROUTE 6A
02664 YARMOUTHPORT,MA 02675
Phone: 508-362-4541
Type of Building:Dwelling Lot Size: 12,197.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder.
Other Type of Building: No.of persons: Showers:
Other Fixtures: i
Plan Date:07/21/2015 Number of Sheets: 1
Cafeteria:
Tit1e:TITLE 5 SITE PLAN 4 TEMPLETON PLACE Revision Date:08/20/2015
Design Flow(min.required):220 gpd Calculated design flow:220 gpd Design flow provided:349 gpd
Description of Soils:SEE PLAN
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluation:07/29/2015
DANIEL GONSALVES,SE
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� DESCRIPTION OF REPAIRS OR ALTERATIONS:SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK,DBOX,2-
500 GAL PRECAST CHAMBERS W/4'STONE:25'X 12.83'X 2'
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 Certlficate of Comoliance has been issued bv the Board of Health.
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;
RIKER LAND CONSTRUCTION, P.O. BOX 726, SOUTH YARMOUTH, MA 02664
� To perform: Upgrade an individual sewage disposal system.
,
� Owner: PANKRATZ DAVID J
� PANKRATZ ANDREA
P O BOX 385
REHOBOTH,MA 02769
Location: 4 TEMPLETON PL, WEST YARMOUTH,MA 02673
Disposal System Construction Permit No.: BOHDC-15-3187 , Dated: August 24,2015
' Provided: Construction shall be completed within six months of the date of this permit. All local conditions must be met.
CONDITIONS:
1. SEPTIC DISPOSAL-REPAIR-PROPOSED 1500 GAL SEPTIC TANK, DBOX, 2-500 GAL
PRECAST CHAMBERS W/4'STONE:25'X 12.83'X 2'
2. ZONE II MAXIMUM 2 BEDROOM
��
Bruce G. u phy, 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.
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