HomeMy WebLinkAbout2022 Sign off Transmittal - Demo Deck / Replace with 3 Season room f,,t:Y�ti,y TOWN OF YARMOUTH
:: : -V t
r. HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant:
Building Site Location: cl).�)dS - ---1.--1(k 1 e-9,) q_c-re-- ) pt5 -
Proposed Improvement: _ .% ilia_— of eck -I' e\G-C1I_
t
p §
'/
Applicant: ••.dr _ With.-,-a _ . • . Tel. No`�> (z:)0.-0(c)(4,11
Address: a CA{1 ,r v- E a cf t Date Filed: R I (cA 1. ,. ._
**/f you would like e-mail notification of sign off, please provide e-mail address: � _ •• .
Owner Nan 0f1Dca,.rek.Si
Owner Address: Q(D4,t,04,,,,(......\,,„,,,,,i,-,,,c;67-t— Owner Tel. No.: IS \53
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;
,Lp ' %02i (2.) Floor plan labeling ALL rooms within building
(all existing and proposed) -
HEALTH DEPT. Note: Floor plans not required for decks, sheds, windows, roofing;
f g;
(3.) If necessary, Title 5 application signed by licensed installer
ith fee.
REVIEWED BY: DATE: [ —1- 1' '''.1-1-t-
,.., Z
LEASE NOTE
COMMENTS/CONDITIONS:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
—= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•
9 Debs Hill Rd _
Property Address
John Ranalli
Owner Owner's Name
information is Yarmouth Port MA 02675 3-4-2020
required for every
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
REAR
A $�
0 O D
RECEIVED
SEP ; 20??
HEALTH DEPT
i I A B i
u-6 i i3-6
2 2q - s I4- 10
3 55-0 1 19- 6
4 111- 0 ! 39- 6
•
t5insp.tloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
fl