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HomeMy WebLinkAbout2022 Sign off Transmittal - Partial Basement Finish Sto l‘e 20 i 7-/-/ fivoce. - ohay TOWN OF YARMOUTH eioate io HEALTH DEPARTMENT . �y Ba�e�rlAft.. PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET To be completed by Applicant: Building Site Location: t 5 w ' iv 5 10 W G-R A y -ROA A t7 j2 ST 1141n10 at 17 Proposed Improvement: Ci NIS 14 5 e CT► °,.I v 1% AS E8E44 . _t iv.'" /347-14 rOo1L1 Rt V e,u d- o rct ce 513Ac.e • iU-}C/4I'o ✓ worst_ o ul Applicant: C AR lo 5 I I u e I Roe Tel. No.: Sof 237- 9.� Address: A0 CA P T AJ0 ie 5 R P 5. -I P-iZr''1d urs 62 GG " Date Filed:° S 11 22- C" 6 **If you would like e-mail notification of sign off please provide e-mail address: G ► O� �-00 2. 1/kOi mAM . GOM Owner Name: tjv rev CA l l e Owner Address: 1 5' !n S loco 612 41 i?? Owner Tel. No.: 11`7/ 8 I a q O 91 (-1-Le-5r '1A1211 ur lel MA o Z 117 3 j enn:e j oive,S Cµ 11e e. d3 S I 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; MAY 2 7 2022 (2.) Floor plan labeling ALL rooms within building (all existing and proposed) — HEALTH DEPT. Note: Floor plans not required for decks, sheds, windows, roofing; (3.) If necessary, Title 5 application signed by licensed installer 46 fee. (..;(- CO REVIEWED BY: DATE: P EASE NOTE COMMENTS/CONDITIONS: '. ,......;!-,, „ . • 1 1 I 1 ,. .... . i Hz,.- i , ..... ., . ...... ',......,., i . .,.:.,.,, ' t----:,•:::., 4) ! k ,, - 7 ...C: 0 - -- . - .. . •! 7-4 -- H - , , .,,-. 1 ' i 1 ., 1: . , k, L - ...- 1.A,„(-,:x..../ , .i ;.. ', „...,._ . 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Subsurface Sewage Disposal System Form - Not fc` 'Jotuntar .Assessr is 15 Winskow Grey Rd_ Property Address Michael Marcoux owner Owner's Name irrormasoft es requ!ree brew,/ West Yarmouth MA 02673 10/Z19 C;ryfTown State 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 g 0 Pumping information was provided by the owner, occupant, or Board of Health O X Were any of the system components pumped out in the previous two weeks? N 1 Has the system received normal flows in the previous two week period? E EI Have large volumes of water been introduced to the system recently or as part of this inspection? N L.: Were as built plans of the system obtained and examined?tlf they were not available note as NIA) X 0 Was the facility or dwelhng inspected for signs of sewage back up? (i ❑ Was the site inspected for signs of break out? :4 G Were all system components, Including the SAS, located on site? Z 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? IN; 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 Soli Absorption System(SAS)on the site has been determined based on ?k tx ❑ Existing information. For example, a plan at the Board of Health. g C Determined in the field Of any of the failure criteria related to Pall C is at issue approximation of distance :s unacceptable)(310 CMR 15.302(5)) I. System information Residential Flow Conditions- Number onditionsNumber of bedrooms(design) ' Number of bedrooms(actual) 2 DESIGN flow based on 310 CMR 15.203(for example 110 gpd x#of bedrooms) 330 MAY t• 2022 e.".-.•:VI ills 5 Canal nommeson co.* asbudfror&raw normal Swam•Paps b n't,. HEALTH DEPT Commonwealth of Massachusetts * �, Title 5 Official Inspection Form ... Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'e., ,o /5 ("A 0 S tor,/ rr /Cd Property Address l/� G'Kpr✓ / --"- Owner Owner's Name —vv"��-- information is i!,(// �/) /1/�/ n l /� ? -��J required for every ` d 0,' / '� 0 dl Cj'/� J 9 2 page. Cityfrown , State Zip Code Date of Ins ction D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ! 14- Estimated depth to high ground water: - -- --- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ served site(abutting property/observation hole within 150 feet of SAS) Checked with !owl Board of Health-explain: 1i"vt r 4-- i E5/41 f?O/f ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must dee how you established the high ground water elevation: oC c n.4.4 cis" -f-o /a ��- �o yo k oc%r.�- 72- I41,7---L/ ©f .T�,•tr //? -��s /a -- - �.. -P • _ :S d"! I VlJ 4,d J Fe,-- Ao, _ fS e© � 6 SA._c 7,(A.,,i(Arc›,d--,-,, ___ ____ _ __-- I - Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5mc dos•rev 6/16 Title 5(Aura inspection Form.Subsurface Sewage Disposal System•Pape 18 of 17 I Commonwealth of Massachusetts , Title 5 Official Inspection Form - II Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � IS CNA/kr/OU../7 •-"/;'r Pa/ Property Address// e� 2 inform Owner's Name f /-/.S 7j.,140,4,-/tilt'_ / ,4 (/o)t�' 3 0 information is (f/ required for every page. City/Town State Zip Code Date of I,specti. E. Report Completeness Checklist Inspection Summary:A, B, C, D,or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ID‘em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Mee dee•rev 6/16 Title 5 Oreciai inspection Form:Subsurface Sewage Disposal System•Page 1701 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments tAil A / Cr7-01 Property Address / a 1/ -1,/ f1) t// / iOwner Owner's Nameinformation is (1'e-S4L___jef___'__.4'Ale � /T e�b'/✓ 3o)'g / -- required for every per. City/Town State Zip Code Date o ns e- o D. System Inform- •n (cont.) Sketch Of Sew--- Disposal System: Provide a view of the sewage disposal system, including ties to at least two ,-rmanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p • is water supply enters the building.Check one of the boxes below: 111 and-sketch in the area below ■ drawing attached separately A - d _ _..25 A.L-01- 1 s, ( 1 /13--)-S Q3 325 Title 5 ofrcral inspection Form.Subsurface Sewage Disposal SY%W«n•PaiP 15 of 17 t5ins.cloc•rev 6r16 • 111) ti (13km"nm‘imml"1.".m"' )%1 46141(.% C.0121 / 't O s - v+ • • 4 , 4