HomeMy WebLinkAboutSchool Repair 2486 Ellington Road TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT pr-pliz r`7a,,koh1tv
Application for permit to install a new/repair subsurface sewage disposal system. To the Health Department,
Town of South Windsor.
Fee Paid /0 100 Date r (F-0 4' 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
2 4-8'(, C Le- /'Ch se LJ , and owned by vv .SrN k uV
Street, Address, Lot Number Name
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Address
Information to be supplied by Applicant:
Type of dwelling If non-residential, estimated daily flow
2 dentia Commercial,Etc.
Numberof bedrooms 3 Size of lot
Number of fixtures above basement f 4,
Tubs,Sinks,Toilets,Etc.
Number of fixtures in basement, if any ,
Pumped or gravity flow,
Type of water supply If private,type of well t«>`?)
Pub Cvate
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 E HEALTH DEPARTMENT.
Permit Received b OO�2¢� Date
4,g7nat of Appli 11 cant icense Number
For Office Use Only
Permit issued by Date
System installed by
Final Inspection Approval Date Date -7-ao-ay
AS-BUILT PLAN DATE - /q-o y
Location aga4 Cilia, ars /U A/mAr Town .S-0. 1V,ndS®r
H�oruse Numaerkdrid Street
Installer's Name _) r os New Septic System
Ucense Number _ 3 y 1-�S' TAivk 4 Repair of Existing System
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Draft a substantially correct scale drawing with property boundaries showing separation distances of septic system installation.
Include all of the following information to provide an accurate record of the entire system location:
at least two sides of the building nearest the system.septic tank,distribution boxes.trench ends,dry wells.galleries,potable
water supply wells.and any other features affecting the system and its location. Also indicate the septic lank size and
leach field composition.Le. V x 1'trenches.8'x 10'dry wells.etc.
Show leaching system reserve area and curtain drains,as needed.
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—Point _ 01 #Z #3 x4 #8
Distance from Carver"A" 72 3 _ "° _�...#7 �. #8, #9 #10
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Distance hvm Comer"B" i; •� ,r'
Distance from"C"
Distance from"D"
Revised 9/97
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