HomeMy WebLinkAboutSeptic Repair 167 Ayers Road TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install a new/repair subsurface sewage disposal system. To,the Health Department,
Town of South Wind�sSr.1
Fee Paid �o cd 3Z Date Permit Number
Ada subsurfac je�a ge disposal system nstall r licensed i the State of Connecticut, I
k c -
Name, Address, Telephone Number, License Number
hereby apply for a permit to construct/repair a subsurface sewage disposal sys m loc ted at
av? A:Z R4 and owned by
Street, 'Address, Lot Number Name
X
Address
Information to be supplie y Appli and
Type of dwelling r �L . If non-residential, estimated daily flow
Residential,Commercial,Etc.
Number of bedrooms Size of lot
Number of fixtures above basement
Tubs,Sinks,Toilets,Etc.
Number of fixtures in basement, if any �U ,
Pumped orgravityfl ,
Type of water supply a� . If private,type of well
Public-Private
Information to be supplied by Health Department:
Soil type at various levels
Percolation rate Square feet of effective leaching area required
Size of septic tank Type of system
Trenches,Drywells,Etc.
Number of dry wells, trenches, etc. Distance between individual leaching
units. Distance from well on same property on adjoining property
Curtain drain required
Yes,No
Height of system above ground water maximum ground water ,
ledge , impervious soil layer
If automatic closing is required,description
A PLOT PLAN INDICATING LOCATION OF PROPOSED STRUCTURE, WATER SUPPLY, SEPTIC SYSTEM, EM-
BANKMENTS, WATERCOURSES, PROPERTY LINES AND ALSO INDICATING EXISTING AND PROPOSED
FINISHED GRADES MUST BE SUBMITTED BEFORE THIS PERMIT CAN BE ISSUED.
THIS PERMIT IS NOT TRANSFERRABLE FROM PERSON TO PERSON OR FROM PLACE TO PLACE.
NO PART OF THE SYSTEM SHALL BE BACKFILLED UNTIL IT HAS BEEN INSPECTED AND APPROVED BY THE
SANITARIAN.
SPECIFICATION AND REQUIREMENTS AS STATED IN THIS PERMIT MUST BE MET AND ANY CHANGES MUST
BE APPROVED BY THE TOWN SANITARIAN BEFORE FINAL APPROVAL WILL BE GIVEN.
THIS PERMIT SHALL NOT BE CONSTRUED AS PERMISSION TO CREATE A NUISANCE CONDITION NOR IS
THIS SYSTEM GUARANTEED BY THE HEALTH DEPARTMENT.
a_�U4Permit Received by Date
Sign u e of A licant&License Number
For Office Use Only
Permit issued by Date
System installed by
Final Inspection Approval Date