HomeMy WebLinkAbout2015 Jul 21 - Sign Off Transmittal Sheet, Vision Info, Floor Plans, Inspection Info �
ti. oF�'+!e TOWN OF YARMOUTH
� ,- '�
o - �� HEALTH DEPARTMENT
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•'•, ••` pERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be compdeted by Applicant:
Building Site Location: ��9 � 5 ��2 Gt/� ��
Proposed Im rovement: !�A�'Is'1l'r,�� /2l�o i1- / �<i/�" � �tr �'L�U<Y1
� A��iir��v1 L/-�d20✓�/ ��� oH� r j.r'�
.
��� Applicant: /i'/� / �rH_ � � � �t_- Tel.No.:_S�� 33� /G���
���� -7<<r�
Address: .3�I �'1/�•2 (n/✓�-�/ Date Filed: �j � ' /U• /� �
��
_ •*Ifyou would like e-mail natrficatior!o,�ign t�J;please prrnide e-mail address:
Owner Name: ��f y,�-c / �'��
Owner�lddress: /u OwnerTel.No.: SL� 33//(�c� �
..__...........__..................._........_....._..............._........._........._...................................._:............._...................................................................................._.......................................................................................................
RESIDENTIAL AND/OR COMMERCIAL BUILIIING
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 tocation,
, 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, roofang;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
.. .__......_......_........................._................�... ............................................................................................................................................................................................................::..........................................................................
REVIEWED BY: (/�e3-6 ""V�/l DATE: � i S
PLEASE NOTE
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TROY WILLIAMS �`'�""�� � •���`� fa � ��'r��v�.� �
SEPTIC INSPECTION5 � �
Certified by MA Department of Environmental Protectiun (508) 385-1300
19 Hummet Drive
&iuth [)ennis, MA 0266t1
� CUMMONWI'sAl TH OF MASSACiiUSf:'i'CS
� I'�XF.CU'flVl? OTl�1C'r c�r I?NVIRONMF.N'I'A1.AFI�AIRS
UE!'AR'TMi:N'1' ol� I�:NVIRONM�iN'1'N. PRO'I'I:(YPION
'TI'I'LE 5
QF'FICIAL INSI'I�,C770N FARM11 — NQ7' FQIt VOLUN"1'ARY ASSESSAIF:1`!7'5
SUI2SUR[�ACG SLWACG 111SPOSAI.SYSTI?M FORD4
1'A R'I' A
(:F.FZ'1'I!�!CA'1'ION
Prnpern ndrtress: 39 Astor Way S `,
Sou�h Yarmouth, MA .A;;� �1 '�,` . � � i1 t��
Oaaer'sNamc: NurmaTecoraro ,j �L �+P� �
Uwnn�s Anares,: c/u RicharJ Montague,Davenport Realty �
20 Nocth Main Saeet,So.Yarmowh,MA 02664 �
Date nf Inspedinic Sepcember 13,2006 ��V
�.;=. r �� �� rMC� D
Name of Insprclor. Troy M.Wi1118RIS tlr�
Company Name: Troy Williams Sep[ic Inspeciions �� SFP 2 2 2QU6
Mailing AJAress: 19 llummel Drive
Sou�h Deru�is, MA 02660 IiEALl�rt C)EPT.
Tetephone Number: (506)385-1300
CGR'fIFICA"I'!ON S'1'ATf'D1I•:N7'
I ccntf��that I have personally inspccttJ the sewage Ji<pasal system al lhis address and U�al die informalion reported
below is Irue,atcurate and cnmpltte as of tht time o(ihe inspeciinn 'i he insptction was prrfonned baaed un my
training and experimce in the proper fimction and maimcnance olon si�e sewage disposal systems. l am a DEP
appro�rd s�stem inspntnr pursuanl lo Seclion 15.340��f Title S(319 ('Mlt IS.0001. 'lTie s��ctrm
� Passcs
ConJilionap• 1'asscx
Nceds Iluthcr i.valuauuu t�� dic Lui;d App�uvmg Awhnin�
rails
inspector's 5ignalure: ��,w� ���� Dale: p/I3/ol+
l�he sys�nn inspec�or shall submi� a copy of this inspec�ion�epon�o d�e Appro�ing Autho�ity(Iloa�J of I leahh or �
DFP)wiihin 30 days of aimplcting�Uis inspcctiun. If�he sys�un is s sl�ared system nr I�as a design Ou�v of 10,000
gpd ur greater,the inspectm and Ihe syslem owner shall submit the repott to�he appropriate regionxl ofCice nf the
DEP. Fhe original should 6e srnt lo�he system owner and cnpits saN�o the buyer, if applicaUEe,and the apptoving
audiorily '
Notes and Comnunis
Allhough�yelem meela Niem6dmum reqitiremenls sel brlh by the Maesachuse�ls UeportmaM o�
Ern3rormenlal Protectbn.corli0callon la nol lo be conelruetl m o gunranlee of tuture wo�Mng condihon
of eyalam,plpir�or componants. lhl�Irupecllon represenls Ihe coru111ions nl 1he ayslem ori Ilie Uote ot
Iropectlon rroted a6ove.
•••'TAis report only d�scriLes candilions at Ihe tlme of Inspecllon anJ under Il�e rondilians af use a1 Ih�1
time. 't his inspa�ion dues not aJJress how Ihe sys�eni wi11 perfotm in Ihe luture unAer Il�e same ur different
condltions o(use.
Tide S ��ispection Fomt 6/IS/2000 paFe 1 ot I I
• • Yuge G u1'I I
(11�l�t(:tAIJNSE'liC�'IUN 1�[)1tM -NO'1� ('lllt VO1.UN"1'A�tY ASSP.SSMCLN'fS
SUIiSU1tI+ACI:SIs�yA(;ls IIISP[)SAL SYS77i.M INSI'I�CI'!ON !�l)RM
pA EY►'C
SXsI'I.MY INI'URMA'1'ION
Property Address: 39 Astor Way
Sou[h Yarmouth, MA
�)��„�r: NormaTecoraro
�)a��������i���i�j,���; Seplember13,2006
I�LUW CON�11"fiUNS
ItLS1111SN'I'le►l.
NumLm u(bcd�uunu�i{cSIyB�:_I_.._ �`I4NLL'1 O(UUIIOOIIIY(aGuul}:__�
I)1sSl!iN Il�w h;�xcd mi S 10 C'MR I5.2U3(fu� cxamplc: I 10 gpd x!!u!'Lcdrnnms): ��p._.
Nuudicr ul nit�cul�esidcnls: ' GZ
I�ifCY ICSItIL'lIL'C II�VC il 6'JIIli16C y'11O�IGC�yCS Of ILU): �
IY IJIIIIIIIY�lll u]L'�Ii11diC SCWYb'C 5Y51CIII�yC]UI u0�:�� III yL'Y 5L'�)JfLIC IIl5�7L'CUOiI ICIfl711'Gljl
l.�uud�y syslem iuspnctcd(Ycs n� ni�):�M
Scusuual usa(yc.w o� nu): tyd
Wulci mcicr ieadings, II'uvaila6lc iIJSI 2 YCflI'!11]J6C I6I1tI��: C� `_ ��Lpu 5,�6,,n y v'f e SG�oao ,,,�G��
Sp[ll�l'f1110�1�YCS UI 310): p.0 5
l.ns�da�o u(uccupancy: _Q�.W .a.J�
F -
I:OMM LRCIAi/INl)U5'1721e\I.
'I'ypc uf cs�u6lisLuu:n1:
1)csign I1�ow(l�axd��u 110 CNIIL I520J): _ . _ _gp�
ISusis of Acsign Auw(seuls/persous/sqfi.cltJ:--- -..._ _
(ii'casc I�np�iicscul(ycs u� uu):_ _ _ --____ . _'_.
Indusl�iul wuslc Lulding tauk picscut(yu a nu):
Nuu-saniiury wusic disc6�uged In Il�e"fitke 5 sy� a�(ycs o� iw):
W�uei n�der rc:idings, il'xvailahle: •
{.asl Julc af�>tcupuncyhisc: ---_'-.
O'1'�Il:lt(desc�ibc): _ -- —T.--- -.
CLNISRA(.1N I�Qli7vin'IYON
1'�uuping ItcwrJs
5.�u�ccufwli�uuuuun: �?�r..ps� � Y��B�� /o/��^r.YCii �3o/53Pw lloH.
Was sysicw puwped as pnU uf iLo inspeuiun(yes o� i�): N,a
1(ycs.vulumc�am�pct�:------..Bulluns -- Iluw wux yauulily pwuped dc�cnwncd7 -----'--'
lLcasun fur pnmping:�.------- .__..__...- ----'-"'--------
'fYl'��)1�SYS'�'p,lvl
,�Seplie lunl',dielribnllwrLu�,soil ubso�yNion sysleiu
_ S111bIC CCSS�IOUI
" OvcCfluW Cess�mnl •
_ l'�ivy
Shared syslcm{yns m nu��II yL'S.OIIJLII'IICVWp1 U45�lCCIIOII(CCIHII]�if anY)
��IUWV811YC�/1�1CI'OL�IVC�CC�1Ip1�Ub'�f. /��WL'�1 J CU�Iy O�I�]C CU(fClll O�IClu�lbq 4R�j IlIJl111C11:lOCC CU171fYC���U�IC
oLlaincil lioni�yslein uwucrJ .
_�'Cight lue�k __Allnch a eopy uf�ILo Uldl'u��prnval �
.._OIher(desc�7be):------'- -- _.� _�
Approximalo ugc uf�111 cu�nyu��enls,IIJIC UISIiIIGI�I��IloWll�➢[III9�UIGC UI 111(ulO1JIlU11:
�s.J-�u.r_ „T7 I 1 � L .�y_— C Yr j�__
Wcra sewage euiu�s dqcclui wl�en a�rjving ut�I�c siie(yes ur uu): No
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UI�I�ICIAI. INS�'�:Cl'yUN 1''I)ItM —NO'1' 1�012 y01.UN"1'ARY ASSI�SSMlSN'CS
' SUIiS�1121�AC1? SIS�'AGIs 1)1S�'QSAI.SYS'!�i?M 1NSPl�=C'l7UN I�111i1V1 '
�'Alt't'C
SYS'fl?lyr IN!'PRMA'!'ION(coiu;m��.�y
39 AsEar Way
IYu��ei ly AdiL�css: South Yarmoulh,MA
Norma Tecoraro
o,r��cr: September 13,2006
Aulc n(hupccliuu:
si:a�rcu ot�s�:wnc:�_ n�sl�os.u.svsrLM .
Prnvidc ii s4:elch uf ILe sewaye alispusal syslan�inclnding tics to al]easl lwu pennunent relcrence l'audnmrks or
bcnclwwrks. Lucaic all wcUs wilhin 100 Ccti. 1_ocale wheru puLlie waler sup��ky culers iLe I,ud�iing.
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