HomeMy WebLinkAbout0115 RENDEZVOUS LANE - Health 115 Rendezous Lane
1Branstable
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- LO C ATT.I O N
''I---11�1ST-QLLER-S--IJL1,NlE-�- A-DDRE,SS- --
D147E-PERtA1T--155UED�
O.AT_E_COMP.LI_Qt`ICE_ISSUEQ_:_1_
of n Le,�ch�n
�,Id
07
No.---...U31...... Fs�.......r ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H A TH
....... f� .............OF..... ... .. ..... .. .. ... .�lr..................................................
Appliration -far Uiii.voml Works Totuitrurtinn Vrrniit.
Application is hereby made for a Permit to Construct ( ) or Repair ( 6,-� an Individual Sewage Disposal
/1yst at:
5 a
---------- ---•_. ......................� - --------------
A'D Locati/o�` ddres or Lot No.
- -----•---•-•-----•--------.-•--•--•----••.
W Owner Address
Installer Address
Q ype of Building Size Lot............................Sq. feet
U Dwelling le?No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
QOther fixtures ------ ----------------------------- --- ------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity....._._....gallons Length________________ Width................ Diameter..... .(..----- Depth------------ -
x Disposal Trench No... ---
................ Width._.._ ---------- Total Total Length Total leaching area I---.-.____-s ft.
Seepage Pit No---------------------- Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) 0-
Percolation Test Results Performed by---------------------_----- - ------•---------...... at .__..___ ._----------------....
Test Pit No. I................minutes per inch Depth of Test Pit.........:-........ Depth to ground water.._.____.--:-..----..._.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.--_-_-_..-_--_____. Depth to ground water.-.----.---._---_--.__.
O Description of Soil...._•
V ---------------------------------------------------------------------------- ----------------------------------------------------------•---------------------------------------------------------------
----------------------------------------------------------------------------------------------------- -------------- ---------------------- ---••----
Nature e sirs or Alterations—Answer when a 1
licable--.-__-----._ .�� 4?44
12Q..------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ssued by the board f heil
Signed a'�! ....------. d!?' / � d l
Date
Application Approved B CG"�"`�'�l�aa-.y�L o�c _ CSTAl
----------------
PP PP y ------------------t ...................................... oze
Date
Application Disapproved for the following reasons: •-• -..............
.............•--------....---....---••-------•----------••-•---------.....----•-•---•----•-•------------.----------------•----------•-•-------------------••---•----------•--.....----------......------
Date
Permit No.------�3.7.................................... Issued Pl� D
No......................... Ficiz ...V.w............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H A TH
/.01 ...... OF
Appliritinn -for Dbpoiial Workii Tomitrnrtion Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( Lo j an Individual Sewage Disposal
Syst at
-------•------- ------ .............. .... •.........--------------------------
Locatio dress or Lot No.
t.
Wr Ownery,,,,,
a /- �' . -- /=--- � Address
•--• -
� Installer Address
Q ype of Building Size Lot............................Sq. feet
U Dwelling�iKo. of Bedrooms_____________________................---------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building _______.yp g ________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
_.__
io-
Q Other fixtures -•------------------------------•-------___-_-------------------_------•-•-----------__-._-------------••------•-•---•--••------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow..............................--------------gallons.
WSeptic Tank—Liquid cayacity------____-gallons Length----------•..... Width-__-..----_-_ Diameter................ Depth_-._-_-.-----
x Disposal Trench—No_____________________ Width:_*--------------- Total Length.................... Total leaching area-.__.._.____..._____sq. ft.
Seepage Pit No___ _______________ Diameter.................... Depth below inlet-------------------- Total leaching area..._-..-_--_.-___-sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by----------------- ........................................................ Date------___------------------------------.
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...------.--.--._-.--. -
fs Test Pit No. 2................minutes per inch, .Depth of Test Pit-------------------- Depth to ground water------------------------
0
O Description of Soil-.___ - ._ .>__________
U ------
--------------------------------- ----=------------------------------------------ --------------------------- ---- _--- -----------------_--
U Nature. repairs or Alterations—Answer when applicable.------------ ", ' -1 a......
•
Agreement:
The undersigned.agrees to install -the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ssued by the board,gf hea
- Signed---- 1-------------/'-a
-------••---- '- 4*0- - ------
---
L � f o Date
Application Approved By -- ---------- � ----------------------- ----------!---.-.-_-
J
G - -- - Date
Application Disapproved for the following reasons-----------------------------------------------------------------•--------------------•------------------------•-
--------•--•--•----••--•----------------------------•-----•-------------••-----=---•---•----•----- = --------------------------------------------- -------------------------------------------------
Date
Permit No. '---•------•-------•----------------------- Issued......P, j....... ..........
Die
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ .............................OF..... .............................
(ETertif iratr of ftnutpliattre
TH IS TO ER-9 at the I ividual Sewage Disposal Vistem constructed ( ) or Repaired (Aor
b ! ti.
Installer
at --- -------- - - - - ---- ------------ - ------ -- --
has been installed n accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ _'_?.__7----------------•-- dated.-----------.....................................
THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONS> RUES AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. µ,
-.
DATE.... --�- l....... --?-=..-------------------•.---.--..------. Inspectgr------- -=------------------------------- --............................
THE COMMONWEALTHrOF MASSACHUSETTS
BOARD OF HEA TH
OF_... . ..
No.....-••- -•--
FEE...
Ditivala1 nrk nn parurffiyt rrr t
Permission is hereby granted_. ..
-----------•-----..•...
to Constru ( ) o Repair ( anal Sewage&sposal. S
atNo. ------ ------ ----•-. --••--•-----•• �f ..._...., —
-...
Stree
as shown on the application for Disposal Works Construction Permit iNo.......3.7________ Dated__.. 3_:__75 ._.___..
-------------------------------------------�-_ - H Y--- -
//_ ���" and of Health
DATE------. J -------------------------------------------- o�.V-
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r,/�r• f"'l GLr. ,
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