HomeMy WebLinkAboutSeptic New 24 Green Lane TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install a new/repair subsurface sewage disposal system. To the Health Department,
Town of South Wi dsor. GU13,;231`
Fee Paid ��u, � Date ^l, —v/ 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 ° construct/repair a subsurface sewage isposal system located at
�r cu` �.�� T j� and owned by cr�1::Kr L�:r l 1*-1 .4G'lhr�l�'
i Street, Address, Lot Number Name
Adddress
Information to be supplied by Applicant:
Type of dwelling If non-residential, estimated daily flow
Residential,Commercial,Etc.
Number of bedrooms h/ Size of lot
Number of fixtures above basement I2
Tubs,Sinks,Toilets,Etc.
Number of fixtures in basement, if any
O Pumped or gravity flow,
Type of water supply Rv 3 . If private,type of wel I
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
A PLOT PLAN INDICATING LOCATION OF PROPOSED STRUCTURE, WATER SUPPLY, SEPTIC SYSTEM, EM-
BANKMENTS, WATERCOURSES, PROPERTY LINES AND ALSO INDICATING EXISTING AND PROPOSED
FINISHED GRAD'tS MUST BE SUBMITS 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 A 0/
System installed by d�
Date
Final Inspection Approval � �, 7
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