HomeMy WebLinkAboutUntitled r,o�.;Y�,k,� TOWN OF YARMOUTH
, HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
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Building Site Location: ( 5feAr
Proposed Improvement: 1Z. }0/ P.. w civ c t
Applicant: J e PS- k ��,� i t_ Tel. No.: c0 2.-gro
Address: ? 2,7 ffvKi 1-(t l 07Z-be Date Filed: ?-ZS 22-
**lfyou would like e-mail notification of sign off please provide e-mail address:
Owner Name: —1-e-f v �y �o,� ..(221t.
Owner Address: (2- 5-�Kt n-� {�� �v-O� cy,�� Owner Tel. No.: 7 7 - f O ))�
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:
RECEIVED (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) -
HEALTH DEPT. 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: `
PLEASE NOTE
COMMENTS/CONDITIONS:
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WITH CREM MED. SAND, TO MEET - CEF SAS M AREA SHOWN_ TOP AT .
4 . 9PECt0cAworo5 OF 310 CMR 15.255(3) �!~ pw
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FLOOR PLAN �>i�>' Date DATE DANIEL A
= 20' NOT TO SCALE •
RECEVED
LA 'Z5 2022
HEALTH DEPT.
Town of Yarmouth -
Subsurface j
Sewage Disposal System As-Built Information
Street Address: Qr ri .(r� id N t r'h ` Map: )Cl Parcel:
t4 1
Owner Name: &U e,-r'i' ii Permit#: 'g VI S V196WDCP49-°24
Date Installed: 10J \ 7J
New: Repair 4g
Installer Name: C lASe, r'1 n"I' Installer Phone: 3442' '1413"2 l
Installation of(list all components,both newly installed and xisting to remain in use): c---3( 62,E x 2
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One I n s fA v po/� t res7 i fl�(1rp. lei,f.� i6i i /0e7f/ �
Leach Capacity(gpd): j ye' Ground Water Depth(Inche s //Z i Health Inspection by: V
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As-built Diagram
(Print Clearly In Black/Blue Ink and Use Straight Edge-Label Risers and Zabel Filter)
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