HomeMy WebLinkAboutSeptic Repair 157 Newberry Road TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install a ne=subsurface sewage disposal system. To the Health Department,
Town of South Windsor. 02��1l�cc` a� b94(Y
Fee Paid - _ Date __I _ ( ermit Number
q a subsurface s wage.-disposal system in Mir li a sed in the State of Connecticut, I
Name, Address, Telephone Number, Li bar
bar
hereby apply for a ermit to co struct/repair a subsurface sewage disposal system�locSYed at
N) 3 G and owned by
Street, r�Addre s, Lot Number Name
S
Address
Information to be supplied by Applica t:
Type of dwelling ' AA If non-residential estimated daily flow
Residential,Commercial,Etc.
Number of bedrooms D; 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 l \ 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 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 R eived by Date
Signature of Applicant&License Number
For Office Use Only
Permit issued by Date
System installed by ."IN w. ( �-(,;V► 06 l-
Final Inspection Approval Date
a
/V' ew
�c
6 � - 36
NOTES SOUTH WINDSOR HEALTH DEPARTMENT
LOCATION IS-7 P- rzol
OWNER
TYPE OF WORK
DATE l-- o -07 PE IT PIPE
INSTALLER
INSPECTOR DRAWN BY