HomeMy WebLinkAboutSeptic New 00 Nutmeg Road APPLICATION FOR PERMIT FOR CONSTRUCTION OF SEWAGE DISPOSAL SYSTEM
TO THE HEALTH OFFICER Application No.
f
TOWN OF � 1 Date Z-
I hereby apply for permit to build a sews disposal system for a
(Resi nce, boarding house, hotel, etc.)
Owned by
And located at
To be built by w ' of
in accordance with detailed information stated below.
Signecl-��- -
ell
(Applicant)
GENERAL INFORMATION
1. Estimated population of premises (present) (future)
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2. Description of premises
No. Fixtures
(above basement): Water closets ?� Urinals '� Lavatories Z
Bath Tubs Showers Ki'chen Sinks Laundry Tubs
List fixtures in basement �-
3. Water supply �� Kind of well
(Public, well or cistern spring)
Location of well
Method of obtaining or storing supply
(Pumps,tanks,etc.)
4. Character of soil at proposed location of leaching system, including depths of various strata
(Sand, loam,clay, hardpan,etc.—use test pits)
5. Elevation of ground water
(With reference to both present and future grades)
6. Description of proposed system (Furnish drawings of some, with plot plan showing system)
*SEPTIC TANK
Dimensions �XX Capacity below flow line
Facilities for cleaning
Distance from water supply on same property � � , on adjoining property
Distance from property lines -� >` - Distance from. dwellings on same property
/.O
on adjoining property
Automatic Dosing Apparatus, if any (describe)
**SOIL ABSORPTION SYSTEM
If cesspool, size if ft. diameter and ft. depth below inlet.
If tile field or leaching trenches, total length is J ft.
Width of trenches � -ft, depth f broken stone or screened gravel z�� -Ik. Stone or gravel
will be covered by
(Salt,hay, t paper, etc.)
/ ®d
Distance between trenches ft. Distance from water supply on same property
on adjoining propertyo
Distance from property lines lee) � Distance from dwelling on same property .zf rf
on adjoining property 16d / T ,
SECONDARY TREATMENT, if other than'-soil absorption:
Describe in detail, and locate on map
3'
$ysiem was designed-by = '
Above information furnished by
*If privy or chemical toilet is proposed, submit information as to pit, **No discharge of sewage or sewage effluent into any watercourse
fly proofing, chemical.tanks, etc., on separate sheet. - should be permitted without approval of the State Department of
Health and State Water Commission.
Form 12750.1M-Hull '
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104
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