HomeMy WebLinkAbout1995 Jul 19 - Request for Septic Info FormI
TOWN OF YARMOUT
I 1 Ili R01 TE ?:I SOI Tl 1 YARMOUTH
TCIvl)hunc (508) 398-2231, Ext. 241
MASSACHUSETTS 0266,4-4451 ,
— Fax c 5081 398-2365
B O A R D O F HEALTH
,1 U L 19 1995
REQUEST FOR SEPTIC SYSTEM INFORMATION � �L
(FORM MUST BE FULLY COMPLETED) C
1 • LOCATION OF INSPECTION: 1 �J S' Valli"
2• TOWN ASSESSOR'S MAP #
,LOT # �' 6 � uhf
3. DATE HOUSE WAS BUILT: 9q0s n&0 K�� �Q 0��% � 9,
4. WELL ON PROPERTY, INCLUDING IRRIGATION WELLS? YES NO
(SHOW LOCATION ON SEPTIC INSPECTION FORM.)
5. OWNER'S NAME AND ADDRESS: _ Kot)l G &U Jl.it _
A-r-.hv ►i / ?&
6. BUYER'S NAME AND ADDRESS: 9WIn Sn _0")
B }o Ck-' hT41
7. OTHER INFORMATION REQUESTED:
LLq���
The Health Department will provide:
41. Last four (4) years of septic pumping history;
2. Septic system location "AS -BUILT" card, if on file;
3. Septic system description;
4. Copy of Septic Disposal Application;
5. Percolation card, if on file (New houses since 1980);
6. Review of engineered septic plan, if on file.
ALLOW TEN (10) BUSINESS DAYS FROM DATE OF SUBMITTAL FOR THE HEALTH DEPARTMENT
TO PROVIDE INFORMATION REQUESTED.
ON COMPLETED SEPTIC INSPECTION FORM, ATTACH "AS -BUILT" LOCATION CARD SUPPLIED
BY THE HEALTH DEPART,
MAP AND LOT NUMBER MUST ALSO BE PLACED ON THE ETT PAGE OF THE INSPECTION
FORM.
NAME OF STATE CERTIFIED SEPTIC INSPECTOR:
Troy Williams
ADDRESS: Septic Inspections
40 Old Bass River Road
South Dennis, MA02660-2701
TELPHONE NUMBER: `� r� 21
FILING FEE OF $30.00 PAID ON: Ck l o
T� Printed on
04/06/95 ^ ' 1 � Pane- r d