HomeMy WebLinkAboutSeptic Repair 1084 Ellington Road TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install a new epai subsurface sewage disposal system. To the Health Department,
Town of Sou&6Win sor C-3
Fee Paid �D� Pr
Date 6 Permit Number
a subsurface sewage disposal sy err i staller I' ensed in the State of Connecticut, I
��l y,5, �',[f O sf 4 IM
re �o��/
a , Address, Telephone Number, License Number
hereby apply for a permit to onstru repair subsurface sewage disposal system located at
L_kA' bni X'0 c and owned by
Street, Address, Lot Number Name
Address
Information to be suppA}�ed by Applicant:
Type of dwelling /arc, 1o0E� 14 . If non-residential, estiTT ated daily flow
Residential,Commercial,Etc.
Number of bedrooms Size of lot `f 0 ,C 3
Number of fixtures above basement
Tubs,Sinks,Toilets,Etc.
Number of fixtures in basement, if any ,
Pumped or gravity flow,
Type of water supply C_/7` If private,type of well
Public-Privat
Information to be supplied by Health Department:
Soil type at various levels SAA1—p
Percolation rate Square feet of effective leaching area required
Size of septic tank /OUd 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 7BYHE HEALTH DEPARTMENT.
Permit Received y
Date 71 -�
S gnatu Applicant& icense Number
For Office Use Only
Permit issued by Date
System installed by
Final Inspection Approval Date
l
oy 5`art
�7614
1
NOTES SOUTH WINDSOR HEALTH DEPART14ENT
LOCATION lo6Y LL1MjA,,__
U � ;rck OWNER
TYPE OF WORK • r
DATE l0-7-82- PERMIT PIPE
-INSTALLER -
INSPECTOR GAD DRAWN BY 4c'1�