HomeMy WebLinkAbout2016 Aug 08 - Sign Off Transmittal Sheet, Plans - New Bathroom; Moving Bedroom .o!�-'Ya� TOWN OF YARMOUTH
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PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: �U ,(�C� �r.� at-�'/'1�L
Proposed Improvement: �W -�- T c,�,/�„ , �d�sZ (��,/�
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Applicant: oc..E �,�1 c�� ,�-�.;�. � Tel. No�� '' ��
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Address: ��-- �.!"� c��.„�� 2 G-�����/1/��--Date Filed: O I
**If you woudd like e-mail notification of sign off,please provide e-mail address: [ o (� s-,�?� C�Me� S�, ��O e
Owner Name: 1�4 w--2_ '` ` �
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Owner Address: ��`�-�C�O�' er Tel�.N��� / ^ �1 ? � ,
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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. j
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Please submit three (3) copies of plans, to include: i
(l.) Site Plan showing existing buildings, water line location,
and septic system location;
(2.) Floor plan.labeling ALL rooms within building
(all existing and proposed) —
Note:Floor plans not required for decks,sheds, windows, roofing; I
(3.) If necessary, Title 5 application signed by licensed installer �
with fee. ;
............................................................................:..:..:................... . ....::.: ......._ .......:........................................... ...:....: ......._ .:............:.....:.......... ...............:..................................................._ !
REVIEWED BY: DATE: � � Ij� r
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PLEASE NOTE �
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LOT 16
NOTE:
SEPTIC SHOWN PER TOWN RECORD.
1 21.62'
LEGEND
WATER SERVICE LINE —W—
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RECEIVED
AUG 0 8 2016
HEALTH DEPT.
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PLAN REF:
DEED REF:
ASSESSOR'S MAP:
ZONING:
SETBACKS:
FLOOD ZONE:
PANEL NUMBER:
DATED:
IV nI
145-67
7190-38
33/213
R25
30'-15'-20'
AE
25001C 0589 J
7/16/14
PLOT PLAN OF LAND
LOCATED AT:
115 EVERGREEN STREET
SOUTH YARMOUTH, MA
n PREPARED FOR:
IfO MTOALL DAVID HILL
RE ULAS JU LY 23, 2015
DE
E V:
REV:
REV:
YANKEE LAND SURVEY LLC
153 LOVELLS LANE
MARSTONS MILLS, MA
TEL: (508)428-0055 FAX: (508)420-5553
yonkeesurvey@comcost.net www.yankeesurvey.net
Ll SHEET 1 OF 1 JOB¢#: 55132 JM
EXI5TING FLOOR PLAN
1025 50 FT
0 I 5
® SCALE
Existing Fl000r Plan
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EXISTING KITCHEN/DINING NG
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EXISTING BEDROOM EXISTING LIVIV& (NO CHANGES) BEDROOM �
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EXIST'
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136150 FT
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SCALE
1st Floor Existing and Proposed
RECEIVED
AUG 0 8 2016
HEALTH DEPT.
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DATE:
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SCALE:
SHEET:
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EXIST'
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SCALE
1st Floor Existing and Proposed
RECEIVED
AUG 0 8 2016
HEALTH DEPT.
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DATE:
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SCALE:
SHEET:
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�� Commonwealth of Massachusetts ��ySp��-�l--i�h �r' �`�d`t'��' ° � g"��'P°"^
Title 5 Official Ins ection Form �'"� "° � '�`"h°�" SN�` �
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Subsurtace Sewage Disposal System Fortn-Not for Voluntary Assessments
115 Evergreen Street, South Yarmouth M �33 1� �d r 3
Property Address � �'M:;/��r` `��
David&Lisa Hiil � E�
�e� Owner's Name '�m'
information is 12 Greenlot Circie, Lakevilie MA 02347 June 15,2016 � �
required for every
page. CilylTown State Zip Code Date of Inspedion
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
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''"�°'�"`:"�1e" A. General Information
fiir�o��� JU�d � t� �l�tb
on the computer,
use only the tab 1. Inspector:
key to move your HEALT�-a DEPT.
cursor-do not Troy wlliams
key.��um Name of Inspector � �
Tro Williams Se tic Ins 'ons ��' � � f�
� Company Name ' � ` s � �[
� :
19 Hummel Drive ' � � -'� � �:
Company Address
� South Dennis MA 02660
City/Town State Zip Code
(508)385-1300 SI682
Telephone Number Lioense Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was perFonned based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Tttle 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ❑ Fails
� Needs Further Evaluation by the Local Approving Authority
S�..o-�. � June 15,2016
Inspector's Sgnatu Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspecto�and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
*""*This report only d�cribes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will pertorm in the future under
the same or different conditions of use.
t5ins•3H 3 � Tifle 5 Ofidal Inapection Form:Subsurface Sewape Disposal System•Pape t of 17
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