HomeMy WebLinkAbout2019 Mar 13 - Sign Off Transmittal, Floor Plans - Finish Basement TOWN OF YARMOUTH
;:-`;'11:14,A_ ° HEALTH DEPARTMENT
Y -^ PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
l t e. tie d P r'c Y icc c e . yeLoyto p( tBuilding Site Location: � �
Proposed ImproveDent: s� b&J , - incl tAv t, eurvt- ('v o_ i /
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Applicant: itAlkt ,F /(C )k�f f Tel. No.: -7--no flL
Address: o 84 Ver TG-C(_ Date Filed: 3//3/l 7
**Ifyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: t i Ke * 6 c,-/I c,A;f
Owner Address: 1{0 8 d li td ut. , c c.L y, riarl_ 04- Owner Tel. No.: 6/7—7fd p73
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.
Please submit three (3) copies of plans, to include:
(1.) 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;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
2 •
REVIEWED BY: DATE: 3//3 AT
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Commonwealth of Massachusetts
,* *.1i Title 5 Official Inspection Form
r
0 s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
-ry ��11 40 Belvedere Terrace
r
Property Address
Add1 ess
DeFeuria
Owner Owner's Name
information is
required for every Yarmouth Port MA 02675 06/02/18
Palle• City/Town State Tap Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below:
® hand-sketch in the area below
0 drawing attached separately
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t5kis•3113 Me 5 O!lklal brepecbon Form:Subsurface Sewage Disposal System•Page 15 of 17
t Commonwealth of Massachusetts
* Title 5 Official Inspection Form
* ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Belvedere Terrace
Property Address
DeFeuria
Owner Owner's Name
requiredis Yarmouth Port MA 02675 06/02/18
rerequiredfor every
Page. CiCity/TownState Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® 0 Pumping information was provided by the owner, occupant, or Board of Health
O ® Were any of the system components pumped out in the previous two weeks?
• 0 Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® 0 Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
►� 0 Were all system components, excluding the SAS, located on site?
►moi 0 Were the septic tank manholes uncovered,opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® 0 Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 471
Gins•3113 Ta.5 OAldal inspection Form:Subsurface Sewape Disposal System•Page 6 o(17