HomeMy WebLinkAbout2023 Sign Off Transmittal - Front Porch TOWN OF YARMOUTH
c HEALTH DEPARTMENT
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• so, PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: L4LE /-b 0,) 6 . a��nn�UT 1iv\ ,
Proposed Improvement: k)1 L_\ \�(ii I rk I�,,
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Applicant: t),i2s,La Gz RF,r R a 'vr..aG N Jb c Tel. No.: _60g. tic, 5 t L G
Address: l 93 c. a pf 1 j 5 .J, `- a .443011-k )(AN l „ Date Filed:
**If you would like e-mail notification of sign off,please provide e-mail address:
Owner Name: L du Ka rev 0.5 a
Owner Address: LIL( Ho es R . ��y\/\czU -'-k Owner Tel. No.: g789
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.
RECEIVED Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
APR 06 2023 and septic system location;
HEALTH DEPT. O (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: la/y....4c) DATE: S- / 3
PLEASE NOTE
COMMENTS/CONDITIONS:
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Commonwealth of Massachusetts
f---4t Title 5 Official Inspection Form
_ '- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44- Howes Road -
Property Address
Gabriel Perez
Owner — — ----- — --
Owner's Name
information is required for every South Yarmouth MA 02664 1/11/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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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s29 ' tat = 57 ' 33 = 351
P2= 3-7 ' 132 = 34 ' C3 = II
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HEALTH DEPT