HomeMy WebLinkAbout2006 Oct 02 - Sign Off Transmittal Sheet, Plans - Convert Garage to BR, Bath a � . .�., ,.�. _.. ,..:.. .._ .�,,. .., , �. .. .> . f .;y. .. �i
. . .. ,. . ..F , �.. , .. � t..`.. . . , � :q . 4 . f�. 4.a`F*s'n
+ t �a .. ♦ • � �
°��Y`''4 + " TOWN OF YARMOUTH
�
o� y HEALTH DEPARTMENT
N�„„��,��x
�' ., PERMIT APPLICATIpN SIGN OFF TRANSMTITAL SHEET
To be completed by Applicant:
Building SiteLocation: Yu d U//N S�-6� GIZaSY�D �/�'�612Mi�Gll�apNo.:
� Lot No.:'�+
Proposed Improvement: C u�Ll�Gtt i G.2Tt,A t,� !G' 1��"1`�TZc,6 h1 T �LC�J 4" �
1
Applicarn: �.41///� i� . /�L:l-LL'-�/ Tel. No.: �
Address: `Y �� !�/i�f/S[-o�v Gp,p,73t l�b� /Q/.yi4�/�'/u�/'H /���DaLe Filed: �� c t
**Ifyou would like e-mail rrohfcation ofsign off please provi�k e-marl address:
,,r.
OwnerName: /��� / i,o.,✓� /,��yt.Fy
Owner Address: S'G � Gf//NSc G W G�'Z/yy fZ O- /N-%k/?��Owner Tel. No.: �`0 e�-3y f- ��/�
�, __ ....._.._..._--____.._.......—......._..._--..._—._.._......._._..........._......__._...-----......_...--...___......_..._..._........_.._._.__.._.......__._.._..-----
.._�........—.�-._
!
RESIDENTIAI.ANDlOR COMkIERCIAL BUII.DING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requiremerns
For Septage Disposal and other Public Health Activities.
Please submit four(4) copies of plans, to include:
(1.) Site Plan showing ezisting buildings, water line location,
and septic system location;
(2.) Floor plan labeling ALL rooms within building
(all e�sting and proposed)—
Note:F7oor plaxs not required for decks, shedc, wixdaws, roofing;
(3.) If necessary, Tit}e 5 application signed by licensed installer
with fee.
-------_____-- -...__ ___..._._..._._........_.._....................._............__....__..........._........__._....__._._........_......._....___.....__..
REVIEWED BY: DATE: f�����9
PLEASE NOTE
COMMENTS/CONDITIONS: ^�
E�t1JSG G U�-+h F' ✓'C/"�^ d� � � /�VvU�C�
. . . . .
- ---�
• ' � � �------
_._.__..._
� __ _._.._.___.__._
1 � �
��
}
5�db�
_-.--------_"
� �
'�.3
.```
���
�3'� XJ 1� a o t�'t
�
ti
d �
V
� . ^
v . _.., /�-�y
_. .._ ��✓ �� � �
� �
�
Cr'SW ��r�� /� 0 6�' _,_
j•��4''9+�? h`tq w TrA?' i4'��.
y��' W°���r :rT'fJ ,v??�.--
� COMMONWEALTH OF MASSACHUSETTS
� Title 5 Official Inspection Form
'a
Not for Voluntary Assessments
Subsurtace Sewage Disposal System Forrn
Inspection resutts must be suhmitted on this torm. Inspection forms may not be attered in any way.
A. General Information
1. Property Information:
408 WINSLOW GRAY ROAD —WEST YARMOUTH, MA 02673
.Property Address �
KELLY, DAVID
Owner's Name
408 WINSLOW GRAY ROAD
Owner's Address
WEST YARMOUTH MA 02673
CdylTown � State Zip Code _
SEPTEMBER 14, 2006
Date
2. Inspector:
JAMES D. SEARS
�F Name of Inspector
A& B CANCO
Company Name
350 MAIN STREET
Company Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
508-775-2800
Telephone Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurete and complete as of the time of the inspection. The inspection was pertormed based on my training
and experience in the proper function and maiMenance of on sde sewage disposal systems. I am a DEP approved
system inspector pursuant to Section 15.340 of Trtle 6(910 CMR 15.000). The System:
� Passes � Cond'Rionally Passes � Fails
� Further Evaluation by the gcal Approving Authority
- G a6
I gp or's Signature: � Date:
/
� The system inspector shall submit a copy ot this inspection report to the Approving Authority(Board of Health or DEP)
within 30 days of completing this inspection. If the system is a shared system ar has a design Flow of 10,000 gpd or
greater,the inspector and the system owner shall submd the report to the appropriate regional office of the DEP. The
original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority.
� ""This report only describes conditions at the time of inspec[ion and under the condkions of use at that time.
This inspection does not address how the system will pertorm in the future under the same or diftererrt
cond'Rions of use. � '�
' Tide 5 Official Inspection Form:Su6suRace Sewage Disposal Sys[em
Page 1 of 16
I ( •� CQMMONWEALTH dF MAS3ACNUSETT'S
_ : v� Title 5 Qfficial Inspection Form
� Not for Voiuntary Assessments
Subsurface Sewage Qisposai System Form
D. System information {cant.)
4Q8 WlNSLOW GRAY F20AD
Property Address �
WEST YARMOUTH MA 02678
� Cityl7own State Zip Code
KELLY, DAVfQ
Owner's Name
SEPTEMBER 14, 2006
`� � Date of inspectioa
(l` � � � �
1 f
Sketch of 5ewage Dispcsal System: Provide a sketch of the sewage disposal system including ties to aC
IeasLtwa parmanent reference landmarks or benchmatks. locate�aH weits within 104 feet. �pcate where
f public water supply enters che building � '
r
/
(1 �^
t
r
_ � Z �fi
�.� iL
1'�
, ���
��,-�
���
� } �
��
0
�
� ?'RIr 5��tiic:al:nxpr::e�ai'��.rc�Su6iur!:�:o JasoSeii�st+.�x:il<�-s�ta
. P.r,e�: .i�.S
:
• ,. COMMQNWEALTN OF MASSAGNUSETTS
- � Title 5 {�ff�cial Inspection Form
Nat for Voiuntary Assessments
Subsurface Sewage C}isposat System Form
D. System Informatian {cant.}
408 WINSLOW GRAY ROAD
Property Address �
WEST YARMOUTH MA 02673
CRyRown . State Zip Code
� KELLY, dAVID
Owner's Name
SEP?EMBER 14, 2006
Date af i�upection
Site Exam:
S3ope
Surface water
Check ce1#ar
Shaiiow waiis
Estimated depth to NO gro�nd water. 12'
" Piease indicate aii methods usecf to determine the high ground water elevation:
� Obtained from system design plans pn recard
!#checked, date of design pla�reviewed�.
Date
� Observed site(abutting property/observation hoie within 150 feet of SAS}
i � Checked with tocai Board of HeaEth—expiain:
, ❑ Ghecked with local excavators,installers—{attach documentation)
F � Accessed USGS database—explain:
You muat descnbe how you astabiished the high graund water eievation:
TEST HOLE AT 12' NO WA7ER.
TEST HOLE AT 4' BELOW BOTTOM OF PIT.
'�N �.P9b :.
r
G
V �
� � �
� C //L i�1. :ld<:;ql�iu.i I:�.pec:mn F,.:m .iu+.iaY:ic.:;«c:i_:liu.Pnsal:ysmm
:I � �' r � � P.,g. Idnf ln
7
/L a Yt-�i�?r4>L