HomeMy WebLinkAboutSeptic Repair 67 McGuire Road FORM42 State of Connecticut Department of Public Health APPLICATION Nu.
INVESTIGATION FOR SEWAGE DISPOSAL SYSTEM
Owner Location
PERCOLATION TESTS:(Record all Tests) et`046 SOIL MOISTURE:
(Date) (high,med ow, tc.)
k TEST READINGS
FHOLE HOLE HOLE HOLE
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10 f?
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TABULATION OF TEST RESULTS
Hole Location Depth Presoak Time Percolation Rate
OBSERVATION PITS:(Record all pits) Groundwater Table
(Date) (Near max.,,Below max"etc.).
SOIL DESCRIPTIONS
PIT 5—
PIT-. PITPTT L
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A4
G" u Q •�' L� Per f I`efiwd 7") 4, wy& I W_
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TABULATION OF TEST RESULTS
Pit Location Depth Ledge Ground Water Mottling
Rain
iivoo
49
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 Windsor.
Fee Paid ®W Zo 'f 6 Date II _16- 01 Permit Number
As a subsurface sewage disposal system installer licensed in the State of Connecticut, I
/"2AVZ P G/9 R LSy -J /`'Z'p a r- ry k-A k,c` 0 ft'r,�'.g rt a v.- C�T' W-?'VS'Z6 co 6g)R'gW
Name, Address, Telephone Number, License Number
hereby apply for a permit to construct/repair a subsurface sewage disposal system located at
p 2268 MArU.46,c NONE and owned by
Street, Address, Lot Number Name
6?
Address
Information to be supplied b Applicant:
Type of dwelling IZ,9_6 i ��4� . If non-residential, estimated daily flow
Residential,Commercial,Etc.
Number of bedrooms G Size of lot 136
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 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 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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