HomeMy WebLinkAbout2019 Aug 30 - Sign Off Transmittal, As-Built Showing Porposed Deck •
d Y A. TOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
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To be completed by Applicant: ,
Building Site Location: G ecvi- tki esit-rP4
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Proposed Improvement: Pec",-,�1' c ngg deck /y x/y
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Applicant: Tcav&r k e tawseto Tel. No.: 5-045-- 674 —fir660
Address: , - •mac, t t s 4-r-rm, '„( Date Filed: qv 6 0/9.
*If you would like e-mail notification of sign off please provide e-mail address: 111(.1 ct,tiS`ho. (\ r'ui-, p-f
Owner Name: 1c r e*- }'u\e wry)"
Owner Address: `, �.-i YVk U a , f e ti Owner Tel. No.: 3o -5 'o - `l7
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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.
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.
REVIEWED BY: (1) \\*/(/ '
DATE: 813C/I e(-
PLEASE
(PLEASE NOTE
COMMENTS/CONDITIONS:
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Town of Yarmouth -
Subsurface Sewage Disposal System As-Built Information
Street Address: 2 03 & r W - Map/OfP rcel: 1
/47—ff 7 I 1 Y
Owner Name: �i2Aci4GS , O �f l�~t' WI, ..41•1.5o,! Permit#: BbH DC 19 -0377
Date Installed: O /Z "" / 1 New: Repair: x _
Installer Name: CAP'E W I'bb £/tTei-'Q,ttl Palgegr 5. D((Z installer Phone;- R q 17 t" 24'7 7
Installation of(list all components,both newly installed and existing to remain in use):
Zrt& i New N2D -80-x w .1 fl,jsR + TAi C rkT
Leach Capacity(gpd): """.". Ground Water Depth(inches): Health Inspection by: t Com,
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As-built Diagram
(Print Clearly in Black/Blue Ink and Use Straight Edge—Label Risers and Zabel Filter)
RECEIVED R)
AUG 1'91019
JEMC,
HEALTH DEPT •
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RECEIVED I , ikammi -
AUG 302019
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HEALTH DEPT.
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