HomeMy WebLinkAboutSeptic Repair 68Burnham Street Burnham S TOWN OF SOUTH WINDSORi 1 „
HEALTH DEPARTMENT
Application for permit to install a new/repair subsurface sewage disposal system. To the Health Department,
Town of Sou h Windsor.
Fee Paid Poems d ���� Date Permit Number
As a subsurface sewage disposal sys em in al r licensed in the State of Connecticut, I
5 ,�`0. S KQ,►,�Q.a-� CIA O Etch Abo-(213-3�C. ;Y9 J
Name, 01 Address, Telephone Number, License Number
hereby apply for a permit to construct/repair a subsurface sewage disposal system located at
Na 122 v'` and owned by TV +',�4 �,�s�( 41,,,1141
Street, Address, Lot Number Name
�0 `t� �.�1�a--y. S 1— S t•J
Address
Information to be supplied by Applicant:
Type of dwelling Cil4dA-C- n= . If non-residential, estimated daily flow 7 a
Residential,Commercial,Etc.
Number of bedrooms Al Size of lot
Number of fixtures above basement l 7
Tubs,Sinks,Toilets,Etc. /
Number of fixtures in basement, if any Gr ur� „t _ A'�_'J'aQ lYs�ic%�
P ped or gravity ow,
Type of water supply R"b E. 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
I
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 Y T E H AL H DEPARTMENT.
Permit Received by �7 Date `G C <r t ( ��
.lure of A cant Licen e N b r
For Office Use Only
Permit issued by Date
System installed by
Final Inspection Approval Date