HomeMy WebLinkAboutSeptic Repair 1060 Ellington Road z TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install a new/repair subsurface sewage disposal system. To the Health Department,
Town of Sout n or. 5'--'f-- 3
Fee Paid 1� Date 16,1672 Permit Number
As a subsurface sewage disposal system installer licensed in the State of Connecticut, I
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Name, Address, Telephone Number, License Number
hereby apply for a permit to construct/repair a subsurface sewage disposal system located at
/DC�D M'f k T �� and owned by .j,ea
Street, Address, Lot Number Name
5avf� �
Address
Information to be supplied by Applicant:
Type of dwelling ,416L4 T� . 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 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 is°y 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.
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Permit Received by P, Date
a
Sig ature o Applicant&L ense Number
For Office Use Only
Permit issued by Date
System installed by
Final Inspection Approval ��� Date �`g3
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NOTES SOUTH WINDSOR HEALTH DEPARTMENT
LOCATION i a6o
OWNER
TYPE OF WORK to -fit 8�
DATE .5=-S P IT PIPE
INSTALLER
INSPECTOR !"d�y DRAWN BY
FORM #•1 SOUTH W1NDS R HEALTH DEPARTMENT
a
ti APPLICATION FOR PERMIT TO CONSTRUCT OR REPAIR A SEWAGE DISPOSAL SYSTEM
(office -Use On3y)
APPLICATION 90.
TO THE DIRE7CTOR OF HEALTH
TOWN CP DATE_ 'Y-9-
Application is hereby made for permit to construct a sewage disposal system for a
(-Residence, Store, Re -- s Ste.
Located at Q
�_Street Address., Number, Subdivisioa Name; Map, Block, Lot, Etc•
New System Addition Repair Other
Other
T,1w4c'CA y
Owner / n• du ,s, Address 7.7- Tel.No.
Installer '?`<< y� . �I�� Addresses r? i,t ;, A LI/ Tel.No.Ce .3
Installer License No. Jofi,�
In accordance with detailed information stated below
Signed i
v (6mer`o duly authorized representative)
Application fee paid
GENERAL INFORMATION
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Subdivision Approved Date Lot size Sq. rt.
On Public Water Supply Watershed }�y�j� i L �,ti,p C On Designated Wetland
SCS Soil Classification Public Sewer Scheduled
Date
If residential, number of bedrooms Flood zone
_f non-residential, design criteria;
(Sanitary Facilities No. of Employees, Meals Served, Etc.)
Basement Fixtures Foundation Drains
Special Equipment
ENGINEER'S PLAN REQUIRED
TEST DURING SEASON
Water Supply Type Well
a
Well Location Approved Yield Satisfactory Sample
(Date)
Well Driller's Name Address
rWATER SUPPLY APPROVED
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