HomeMy WebLinkAbout2022 Sign of Transmittal - Replace existing deck TOWN OF YARMOUTH
A HEALTH DEPARTMENT
'�•`` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant.
Building Site Location: ��i- �e ► ) ' r K-c-
Proposed Improvement: f , ! / PT `'c>r c ;
Applicant: i'_. (ti 11-4 Cc) Tel. No.: G r , ,
Address: IC' fit t-o(.Jtetie a</ - Wert '=: 11/1 C)2 ' Date Filed:
**lfyou would like e-mail notification of sign off please provide e-mail address: (lc /vner `Y'el,t r 1. (C111
Owner Name: ' --_ill( c='
Owner Address: ,,.� (,3e + /Q r f..r/a/r.c.v.r4 fit/Owner Tel. No.:9-7 - %77
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:
(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;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: / ' DATE: 3 (7' c
/)-2"--
PLEASE NOTE
COMMENTS/CONDITIONS:
F}`' Commonwealth of Massachusetts
+4- MAK 1 t1UYL
frycr1 Title 5 Official Inspection Form
' i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments HEALTH DEPT.
`- �'" 40 CAPT WEILER RD
v,�.-��-..ate
Property Address
PAUL & CATHERINE LESSARD- 16 LANDRY RD, MEDFORD MA 02155
Owner Owner's Name
information s S YARMOUTH
required for every MA 02664 2/21/2022
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
❑ drawing attached separately
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