HomeMy WebLinkAbout2022 Sign off Transmittal - New Deck of Yak TOWN OF YARMOUTH
tt HEALTH DEPARTMENT
'�• '� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To he completed by Applicant: /
Building Site Location: IS A/a�Se-ti LA) asf-`/�- 4e. /t
Proposed Improvement: ha;1 h e v /2 X 3$ r e c2c.t O ei
64.6k oC_ AQe.c-e
Applicant: f eI/I71.-4e Tel. No.: Sb$ 776' S7?6
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Address: /6 1- i 4/u oc-1 A 66,i 14 C ?5" Date Filed: /6/it DOD-2
**If you would like e-mail notification of sign off, please provide e-mail address:
Owner Name: Rabic( h an'e roc :au9 s'
Owner Address: /5 A lese?L,i / to >Li--ruiz.-4- Owner Tel. No.:
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:
RL `',. .] (1.) Site Plan showing existing buildings, water line location,
and septic system location;
• (2.) Floor plan labeling ALL rooms within building
HEALTH DEPT. (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: /O At/2-2--
PLEASE NOTE
COMMENTS/COND TIONS:
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Town of Yarmouth
Subsurface Sewage Disposal System As-Built Information Street Address: 15 j\J (A I 5Gy (e Q Map: ! Parcel: 5"
Owner Name: P VY4c tic �O'QE.iCQUIC=5 Permit II: OH-bC. " -02.10
Date Installed: 9 ` ZZ 1 ?AO New: Repair:
Installer Name: cofsEe,A- -6, cut_ CO. Installer Phone:508-477- 8877
Installation of(list all components, both newly installed and existing to remain in use):
11 6LJ . 15OO a0.1. PLASTIC T i./iF i L rK --r-v a _ -r iks-i iL. , h/o Z(S
(5) 1.4-21) LC - Ce C.t+Ann 3eLS
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Leach Capacity(gpd): 330 Ground Water Depth(inches): el Health Inspection by: 3C ul-W .1a&
As-built Diagram
(Print Clearly In Black/Blue Ink and Use Straight Edge-Label Risers and Zabel Filter)
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