HomeMy WebLinkAboutSeptic Repair 593 King Street (2) TOWN OF SOUTH WINDSOR
TH DEPARTMENT
Application for permit to install a new/ pair ubsurfa a sewage disposal system. To the Health Department,
Town of South Wind or. Q G/
Fee Paid /0 alp��t��5-B� Date 1 2,0 / b Permit Number
As a subs rfac sewage disposal system installer licensed in the St t of Connecticu I
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Name, Address, Telephone Number, License Number
hereby a ply for permit to construct/repair a subsurface sewage disposal s��jjs,��tem located at
tic S0. 5-r 3 and owned by J6",M /� cKg?
Street, Address Lot Number Name
Sq 3 Kju& S-r- S6 U-C 14 w 4u SoR°
Address
Information to be suppl d by AIIl�p tant:
Type of dwelling If non-residential, estimated daily flow
Resident�Commercial,Etc.
Number of bedrooms 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 1a50 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 BY THE HEALTH DEPARTMENT.
Permit Received by %JJ e Date
Signature of Applicant&License Number
For Office Use Only
Permit issued by Date
System installed by
Final Inspection Approval Date
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NOTES SOUTH WINDSOR HEALTH DEPARTMENT
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`' p— ° A OWNER
TYPE OF WORK Rwlter 74e 6s T
DATE - - L PERMIT PIPE
INSTALLER
INSPECTOR D DRAWN BY