HomeMy WebLinkAbout2023 Sign off Transmittal - Enclose existing deck ole-f ' k TOWN OF YARMOUTH
...•:'' - iliti-1.* c' HEALTH DEPARTMENT
• T>,..'� PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: cam, �/� -}
Building Site Location: `J — T c, I Stu c- -e 1 , l
Proposed Improvement: r v` C, (05-e 'eY6 I 0 eC
Applicant: -,�,�%�I ,e Li2 Tel. No.: 7 73 y /2
Address: Date Filed: Z 2.7z�23
**Ifyou would like e-mail notification of sign off,please provide e-mail address:
Owner Name: \J = / I / Q_ 4_0 41i,5
Owner Address: Z 1 S j Owner Tel. No.: j-1, Fr 2377923
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;
4 (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: DATE: d` 3
PLEASE NOTE
COMMENTS/CONDITIONS:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
716„77 " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 29 Setucket Road, Yarmouth Port M- 143 P- 140
Property Address
Diane Ohns do David Glowacki The Trust Company of Toledo
Owner ---—------- — — -- — -- —
Owner's Name
information is required for every 1630 Timberwolf Road, Holland OH— �43528 January 27, 2016
- — --— - -- _- —-— - — -- - -_ --
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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Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17