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Board of Hea46 ROUTE 28 , MA.
9b. YARMOUTH MA
APPLICATION FOP DISPOSAL ����� eMTRUCTI®N PERMIT
Application for a Permit to Construct(o) Repair( ) Upgrade() Abandon() - Complete System ❑ Individual Components
4mica # i:�-1 A- -,q P)
Location Lot 1 , Town Brook Rd.
Owner's Name Martha Lincoln
Map/Parcel# 45 73,1
Address 31 Northeast 23rd Ave, Pom
Lot# 1
Telephone#
Installer's Name PKM Excavation
Designer's Name Sweetser Eng.
Address 65 Hokum Rock Rd. , Dennis
Address 235 Gr. Western Rd. , Denn
Telephone# 385-5993
Telephone# 398-3922
Type of Building Two family Duplex Lot Size 50,100 S sq. ft.
Dwelling - No. of Bedrooms Garbage grinder 44 -o
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow �� Design flow provided gpd
Plan: Date 1/29/04 Number of sheets 1 Revision Date
Title Proposed Septic Design Lot 1, Town Brook Rd.West Yarmouth,Ma.
Description ofSoil (s) See Plan
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further fts
ne the t operation until a Certificate o as been issued by the Board of Health.
r Signed Date
Inspections
No.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
CERTIFICAT®F COMPLIANCE
FEE [d([[_X-
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Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disp sal System; Constructed ((j�, Repaired ( ), Upgraded ( ), Abandoned
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by: 44- L&4 f
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has been installed in a cordance with the pro�'sions of 310 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. _ dated -2— / 1 -4 Approved Design Flow 4(gPd)
Installer /Al -
Designer: Inspector: Date: _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.7r
r
COMMON 1111 Of MASSACHUSETTS
Board of Health, ,fid'%=! " MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;
at 14 T e3 1,
FEE
472f 6(40-
Repair(, ) Upgrade( ) Abandon( ) an individual sewage disposal system
described in the application for
Disposal System Construction Permit No. (fT , datedwe
Provided: Construction shall be completed within th+ePs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date > r{ Board of Health X
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