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® ASSACHUSETTS ck4l asa_7
Board of Health, I _6Rmoy r 4 , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repaiaik� Upgrade( ) Abandon() - ❑ Complete System ,individual Components
Location
Owner's Name
Map/Parcel# , j'y /
Address fn .
Lot# C;Ljj
Telephone# 04.. 6 1; . V"'5 54
Installer's Name O
i Designer's Name
Address
$ Address
Telephone#Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to ins a ab o described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to a the sys in operation until a Certificate of Coippliance has been issued by the Board of Health.
Signed — Date
Inspection
�.r
No. !:r ;., FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, YPSfzm 3yT'" , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: YIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 1. , a ' r sOTtf)�`�9F Yf,a
has been iifsstaalled in accoidAnce wild ' provisions q£310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. I dated 6 ' Approved Design Flow (gpd)
s r . s,: r. ` i� f r2 2� Inspector: o j a
Designer. '�< /t 1, p �'• `�.,�- T,� ._, Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
4 ` v,4 Y
No. i i±',X I +`1 dt ,`?j�� "�41.'� i"1L S r FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, T A,?4-S0UTiA , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
v �r % a
at ��'.raa ��%� :hk s""f'i?/.,�(„��•. as described in the application for
. j
:�
Disposal System Construction Permit No. i r ;; dated f� U
Provided: Construction shall be completed within thy' s of the date of this permit.. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date "-) �� ` Board of Health
� '. � .
No.:BOHDGIS-2368
Commonwealth of Massachusetts Faa
555.00
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERNIIT
I
Application for a Permit to:Upgrade-Individual Component(s)
� Localloo:6 IW LN, SOUTH YARMOUTH, MA 02664 � Owner:
. TANNEBRING ROLAND E TR(EST OF)
� Map/Parcel�: 059.211 GO HICKEY NDITH
42 CHASE AVE
VINEYARD HAVEN,M.4 02568-6428
Phone:
Septic System Installer Designer
BORTOLOTTI
P.O. BOX 704 MARSTONS MILLS, MA
02648
Phone:
Type ofBuilding:Dwelling Lot Size:8,712.00 Acres
Dwelling-No.of Bedrooms:2 Garbage Grinder:
! Other Type of Buildiog: No.of persoos: Showers:
Other Fixtures:
Plao Date: Number of Sheets:
Cafeteria:
Title: Revision Date:
Desigo Flow(min.required):220 gpd Calculated design flow:220 gpd Design ilow provided:220 gpd
Descriptioo of Soils: -
Soil Evaluator Form No.: Name of Soil Evaluator: Date of Evaluatioo:
DESCRIPTTON OF REPAIRS OR ALTERATIONS:REPAIR-REPLACE FAII.ED CESSPOOL PER INSPECTION REPORT DATED
. OS/14/2015 W[TH 1500 GAL SEPTIC TANK,DBOX TO EXISTING 6'LEACH PIT
' The undersigned agrees!o insfall the above tlescribed Indivitlual Sewage Dlaposal System in aeeordance with the provislons of
TITLE 6 and furthar aarees not to elace In ooerotion untll a CertiHcafe of Comoliance has heen issued bv the Boartl ef Heakh.
Signed Date
InspecNons
i � . ,
Commonwealth of Massachusetts
; Board of Health, Yarmouth, MA F�
DISPOSAL SYSTEM CONSTRUCTION PERMIT E55.00
I
Permission is herby granted to;
IBORTOLOTTI CONSTRUCTION INC., P.O. BOX 704, MARSTONS MILLS, MA 02648
To perform: Upgrade an individual sewage disposal system.
� Owner: TANNEBRING ROLAND E TR(EST OF)
C/O HICKEY NDITH
42 CHASE AVE
VINEYARD HAVEN,MA 02568-6428
Location:6 IVP LN,SOUTH YARMOUTH,MA 02664
Disposal System Construcrion Permit No.: BOHDC-15-2368,Dated:June 08,2015
Provided:Construction shall be completed wi[hin six months of the da[e of this permi[. All local conditions must be met.
Conditions
I.REPAIR-REPLACE FAILED CESSPOOL PER INSPECTION REPORT DATED OS/14/2015 WITH
1500 GAL SEPTIC TANK, DBOX TO EXISTING 6'LEACH PIT
�CU
Bru Murphy, MPH, R.S., CHO/Amy L.von Hone, R.S.,CHO
Health Diredor/Assistant Health Director
The issuance of t6is permit shall not be construed as a guarantee that the system will function as designed.
I
i
I
Commonwealth of Massachusetts
Board of Health, Yarmouth, l�lLi Fee
CERTIFICATE OF COMPLIANCE $55.00
�
Description of Work:Individual Companent(s)
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by:BORTOLOTTI CONSTRUCTION INC.
at:6 IVY LN,SOUTH YARMOUTH,MA 02664
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-2368,dated 06/24/2015.
Installer:BORTOLOTTI CONSTRUCTION INC.
Address:P.O.BOX 704 MARSTONS MILLS,MA Inspector:AMY VON HONE,R.S.
' 02648
Designer:
Conditions
1.REPAIIt-REPLACE FAILED CESSPOOL PER INSPECTION REPORT DATED OS/14/2015
WITH 1500 GAL SEPTIC TANK,DBOX TO EXISTING 6' L PIT
(�C�/
Bruce G. rp y, MPH, R.S., CHO/A y 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.
BOH_Disposal_Construdion_CofC.rpt