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0-4- SOUTH WINDSOR HEALTH DEPARTMENT
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LOCATION
OWNER au' 1
TYPE OF WORK Gc�
DATE PERMIT PIPE
INSTALLER a e
INSPECTOR () DRAWN BY J?P
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u TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install a ne repair subsurface sewage disposal system. To the Health Department,
Town of South Windsor.
Fee Paid 10-40�/ G" Date —�' Y Permit Number
As a subsurface sewage disposal system ins#aller licensed in the State of Connecticut, I
Name, Address, Telephone Number, License Number
hereby apply for a perm _ At'to construct/repair a subsurface sewage disposal system ogated at
3 4 5 (60_Q Jft_ la;II U4 and owned by 1, .!�_
Street, Address, Lot Number 'Name
`'+ y '-
Address
Information to be sup lied by Applicant:
Type of dwelling -e5 . If non-residential, estimated daily flow
Residential,Commercial,Etc.
Number of bedrooms 3 Size of lot
Number of fixtures above basement
Tubs,Sinks,Toilets,Etc.
Number of fixtures in basement, if any ,
Pumped or gravity flow,
Type of water supply awc': If private,type of well 5k1A)10vs.- '
Pu bl ic-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 10 dt7 Type of system%It GL'
Trenches,Drywells,Etc.
Number of dry wells, trenches, etc. I Tre(vcb Distance between individual leaching
units. Distance from well on same property ���(i� on adjoining property
Curtain drain required tsw
Yes,No
Height of system above ground water maximum ground water ,
ledge ` 0 , 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.
Permit Received by Date
Signature of Applicant&License Number
For Office Use Only
Permit issued by Date
System installed by a
Date
Final Inspection Approval
r SOUTH WINDSQ- R ricAL. ln ucrnn .•nc.v .
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L GATZCtt ?'CR SEWAGE !)=.DCSAL SYS".
o LX=ox 31/5—
(Record all. tests) to`7-g-1 r- St9IL MOI mmr:
Dare , Mid., lov, au
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g 1 Z= #2 aozE SWOU, z l
Tian RsadSas Time Re"Ing '"qme Roactiag Time
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TASMATION Or T-*T ?ESLfLTS
DWA prosaak Mi�.mua .pescs�l� .ioa ee „
o (tawlsoss) Era. (1"i�• Iz �...�..
1
2 us•.an�s
- uus�asa:.r
G3vEFRA'!`IC�R PTIS: (Award all pits) Ground Water Table.
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PIS
PIT A D In. C I P"IT
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4 -36 1` s�s�-{�� Y
U—��_L'flow ft-#( 16 — fa dam era"`'( 36-Gv -
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TABtTIA".'IOR Or 01MMAnCA MPS
Ground
Pit # L�'d1,At water At
A
3
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p=4 SOUTH WINDSOR HEALTH '2• Iavesti�► you tar laga.• s SYs-
DEPARTMENT
a�'?2IAh COI 1=010
st design larger tbaa 2$000 g.p.d. Water supply •�atarshed
3Lgh -mod vat" (less tbaa 44 ;t. ) Possible seasonal high
ground voter
fauxccurse, marsh or paad Possible seascaal tloodiag
kited suitable area Slope over IS%*-
WI6&L=&1 soil (30 - 60 mias./inch) shallow ledge (less than 7 ft.)
�p4crlyiag tight soil (less than !& ft)_� Other
suitable for sewage disposal
Ltasuitable for sexage disposal
—J( Additl=&I investigation rsqusred
?detest during vat season
play requissd .
DZCGN MOWEM ATIONS
Inc� .igated b;� Title
Czm,fi=4d/W4_taessed by Ti`
�ommeats:
aach.marIc location zlevation