HomeMy WebLinkAbout2023 Sign off Transmittal -New front steps oF'YgR TOWN OF YARMOUTH
s 4 °, HEALTH DEPARTMENT
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",.c„_,0 PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant: �
Building Site Location: S v' CAS )/l /2 ( 7,-----1)'/It /2l-mil' J/ '' e
Proposed Improvement: �V' - , A
/4<)/),1.4p4 C0144/4
Applicant: / )a,J/Apo 1-h)h d ..f:ca., Tel. No.: 72V7 ai'2 1/33
Address: S; je.,47 y 6/ei, / - V' " G'''2/1_ Date Filed: ,/ 3
**If you would like e-mail notification of sign off,please provide e-mail address:
Owner Name: 4.1e-?�jz"?, 4/4/Aff,O19
Owner Address: S ..n Ckq � k---): O Owner Tel. No.: 7/ 4,a /f33
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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,
RECEI. '-3 and septic system location;
(2.) Floor plan labeling ALL rooms within building
APR 1 , 2023 (all existing and proposed) —
HEALTH DEPT. Note:Floor plans not required for decks,sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: cam.- C DATE: Jr' rg -
PLEASE NOTE
COMMENTS/CONDITIONS:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (000tinued)
Property Address; 5.2 CZ646' & Cok Ro Y/la Mo 0 fig
Owner. (} ,p
Date of Iarpsotioa: 11 d rR C, /J /[/y/f/Q.s
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at)east two permanect references landmarks or benchmarks
locate all wells within I00'
c n A c = G
40 O _ D : 131
R 11100_16 52
•
,��` RECEIVED
eL
AIM 1 1 2023
CLEAR A a:k RD •
HEALTH DEPT.
DEPTH TO GROUNDWATER
Depth togroundwater: .� feet
method of detar"minatioa or approximation: �/� "�n �
(revised 11/03/95)
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