HomeMy WebLinkAboutSeptic Repair 19 John Fitch Boulevard TOWN OF SOUTH WINDSOR
EALTH DEPARTMENT
Application for permit to install a new epair subsurface sewage disposal system. To the Health Department,
Town of So th Windsor.
Fee Paid 1® Date �� �-� Permit Number _ 2 6-0
As a sus face sewage disposal system in Iler licensed in the State of Connecticut, I
�� :;� s ,a//( ha F�r�-,. ems ' ��o F 7 s
Name, Address, Telephone Number, License Number
hereby apply for a p rmit to construct/repair a subsurface sewage disposal system located at
% 70Aa &,ArA �d�d and owned by J& niyem foa,45-
Street, Address, Lot Number Name
Address
Information to be supplied by Applicant:
Type of. dwelling aiti!n► If non-residential, estimated daily flow
Residential,Commercial,Etc.
Number of bedrooms f)°^ c Size of lot
Number of fixtures above basement
Tubs,Sinks,Toilets,Etc.
Number of fixtures in basWhent, 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 effect! a leaching area required
Size of septic tank 11OD Type of system hr M-S'
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
1
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 HEALT EPAR'MFNT
J ((JJ
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Permit Received by �' Date
Signature of Applicant&License Nu er
f
For Office Use Only
Permit issued by Date
System installed by
Final Inspection Approval Date