HomeMy WebLinkAbout2015 Dec 16 - Sign Off Transmittal Sheet, Floor Plan, Septic Sketch - Deck _ : _ _ � . .
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,oF�qR,y � TOWN OF YARMOUTH 'I
or - ���0 HEALTH DEPARTMENT I�
, �'-�r
� ''�•_��`� s PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET I
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To be completed by Appdicant. �'
Building Site Location: �� ' � �OOK �-� ,� � L✓1/ �
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Proposed Improvement: VJ <=C �� �2 X � 8 �
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Applicant:/�/A2oL(� �. �L c i S�. Tel. No.:�v�'�f', - 33�� i
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Address: 7 '� BQook�ai�L � Wr�e 17�14�I.S DateFiled:/2 /
**Ifyou would like e-marl notrficatron of sigw off,please prrnide e-mail address: /?�1�5 �V���Gl o/ Gt��r-r I
Owner Name: �AmE. _ ;
Owner Address: Owner Tel.No.:
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
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Please submit three (3) copies of plans, to include: �
(1.) Site Plan showing existing buildings,water line location, I
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note:F[oor ptrFns not required for decks,sheds, windows, rooftng;
(3.) If necessary, Title 5 application signed by licensed installer
with fee. i
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REVIEWED BY: �� DATE: � '�` � � �
PLEASE NOTE i
COMMENTS/CONDITIONS: �
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- � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subwrfaee 3ewage Dlsposel Syatem Form •Not for Voluntary AssesameMa
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Roperty Addresa �J /
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requtrediorevery N eS/ `�/a✓'�"'/N__ �
page. qy/ipw� State ZlpCode Date me tbn
D. System Information (cont,)
Sketch Of Sewage Diaposal System: Proude a view of the sewage disposal cyctem, including ties to
at least two permanent reference lantlmarks or benchmarks. Locete all wdls within 100 feot. Lxete
where Ilc water supply entets the building. Check one of the boxes below:
hand-sketch In the area below
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