HomeMy WebLinkAbout5034 0 Forsyth Ave Aquifer Protection District Waiver SignedTOWN OF YARMOUTH
HEALTH DEPARTMENT
PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location:
Proposed Improvement: t� t Iz-yU`tr�r,o �- t4--C_L,Q_...:avNcX)i wsC, _ «� n�
Applicant: STel. No.:fbS
Address: y uc ,UPS OL�j Date Filed: � ► z3
**If you would like e-mail notification of sign off, please provide e-mail address,
Owner N
Owner Address; P.O. BOX 10$ BARNSTABL MA 02630 Owner Tel. No.: 50 3 -12-L7241 7—
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:
(I.) Site Plan showing existing buildings, water line location,
and septic system location;
(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: W DATE: �" ?-0-23
PLEASE NOTE
C MMENTS/CONDITIONS:
:Ebe V_�- rq ut5t a<.,, ck,4 0-f
-f'r rr rr 7 r" tr�G fec`x7/5 .5 �� ) D -5-
A TOWN OF YARMMOVTH BUILDING DEPARTMENT
APPLICATION FOR DETERMINATION OF NON -APPLICABILITY
�O
O1 �. AQUYFE!t PR47EUION BYLAW YLC5.1,1
Applicant/Business Name:6At-'ML- Et�IC+k �A ` �t. T1c�j Date:
Property Owner,
Property location: d #— Lk - unidl�Ilfap��dtN
Proposed Use, ,- frer- JN AD � iep
1. Ras applicant has fully complied with the Submittal Requirements of54B6.5.2 ? L>5
(Attach copy of Hazardous Materials List)
2. Does the proposed use meet all of the Design and Operation requirements of§4o6.5.1, ' S
3. Are the chemicals, pesticides, fuels and other potentially toxic or hazardous materials used or
stored at the site, or produced by the proposed use, in qualities not greater than those
commonly associated with normal household use, _H�
4. hoes the proposed use meet all ofthe objectives and water quality criteria of the bylaw:
The above appticarit hereby acknowledges that the Building Inspector may require the applicant to submit the
matter to the Health Agent or Board of Health, and may require the applicant to demomtrate that he/she hat
received a favorable report from the Health Agent or Board of Health. The Determination, ifrrtade, shill apply
only to the individual applicant and proposed use and shall arrtomatkalty expire upon any change of use or
transfer ofownetsh ip of the business. There shall be no appeal frofn an unfavorable DretermiruAm ofany such
application, new fmm a failure to act, except for tiling by the applicant for a Special Permit from the Board of
Appeals As otherwise provided herein.
Applicant Date nn
Print Name
DETERNITNAVON: The Building Inspector, based upon a review of this application and information
a
y the scant. hereby determines that the proposed use salisf ies the requirementsp ced t apply for a 5 is Permit under §406,
E3uil `n r I) to Ifcalth Agent K
Forts must be filed with the Tolvia Clerk tud copies of this form roust be lost to the following
departnterts (is 11stied in §406.5.4); Water, iEngitrreriag, Fitt, Health. Platsdittg. Coaservadow, Board of
Appeab.
Aquifer Protection District Waiver 05/08
TO: COMIntrcial Applimb in the APD
FROM: Ysmnouth Health Department
SIMECT: Hrmardoiu MakrWa
As PW of hi applkndw Prix M rbr a Board of AX tb hearing or bebarmku w of Noe -Applicability,
PhMG 0001eb d& In= and ftt= it Wide ygnr aPQli R&a For Mother kftnmeloa capcfta �doW h
` WibM cobted the HeaM Des tyke.
in the conduct of you pent aadlor proposed business, do you stoM uJC,
gederde a
Wowing typed oi'produt�? Pug" Chftk to whi Amy of the
ppbr a�i i�r q�,utfya,
Antiirreze. Eat= & R*Hdor Flushes LL Motor on"Ydh�o
ra dic, Brake, Automata¢ Titus. Fluid ILI OasolivdFuels
Grease, Lub* nts -Lo
FloorMriveway Degresscr
BafterY Acid
P.UqtPMfinWUMk rooming
Vehicle Dewmfttoo
Vehicle wawa, Polices
Aaphedt, Tat. S.I.
P,aot, vansfiwm sty DM n=M
Wood Pftservatives iL
Dry CIO=% Solvents„ Carbon Tetrachloride
F6or/bWrnitune 3trippets L
Other Cleaaiag Solvents
IL
Rode salt, Road salt -
Drain, Toilet. Ce�l Clams
Re!frigGtaeta ,
Bug & Tar Removers
IL
Photo ,;
P'rinti ft wo tit Dyes
-LL
Pool Chlorin 6
Pesticide.*, icidea, Herbicides
Jam_
Rud z&jde, pungicides
Nitute Fettilizer
-�
Ievvelry Cleaner
Leather Dyes
-Lo
IL
Elefnopli64 Sludges
06rera olo
Apoicant 3ignatute-
1fEALTAPD09TER ! om