HomeMy WebLinkAbout2023 Sign off Tranmittal - Replace Deck oYrA TOWN OF YARMOUTH
HEALTH DEPARTMENT
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''L `'�14 ' PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: 3 N61,Ecc.vo Z. \-10(,2 tvici-jf-C , V1/1 OZh 7 3
Proposed Improvement: ' e 1 t w .. (le 0*-) 0hc L o-C pcv ,—„,
Applicant: JD pN fief)STel. No.: 7 fir—ci-N—%'/S
Address: ? ( Pak)61,tt,.,coQ Da. '1140-0Aaf(ti MO 0203Date Filed:
"If you would like e-mail notification of sign off,please provide e-mail address: 'j0L ''RltA.,ArS Sielgts e3mQ' it row,
Owner Name: 46 He.) SIB r\
Owner Address: 3 1;NbLE t, 70 ( Z. Owner Tel. No.: 7 F/-S?(-l-9157(,1-
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,
RECEIVED and septic system location;
(2.) Floor plan labeling ALL rooms within building
MAY '�! (all existing and proposed) —
HEALTH DEFT 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: `q
PLEASE NOTE
COMMENTS/CONDITION
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Commonwealth of Massachusetts
-=_, Title 5 Official Inspection Form
= I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-�., . 37 Tanglewwod Dr.
Property Address
Arthur& Delores Zaniboni
Owner Owner's Name
information is required for every West Yarmouth Ma. 02673 5-31-22
. --
City/Town State Zip Code Date of Inspection
page. -
D. System Information (cont.)
14. 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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t5insp doc•rev 7/26/2018 Title 5 Official Inspection Form'Subsurface Sewage Disposal System•Page 16 of 16