HomeMy WebLinkAboutSeptic Repair 54 Miller Road .. TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install a new(repai subsurface sewage disposal system. To the Health Department,
Town of South Win so
Fee Paid /n05- Date Permit Number
As �a subvrface csewa disposal system i staller licensed in the State of Connecticut, I
Name, Address, Telephone Number, License Number
her y apply for a nermit to construct/repair a subsurface sewage disposal system located at
0 and owned by ,i211>fui17,et c,
Street, Address, Lot Number Name
Addre r
Information to be suppind by Applicant:
Type of dwelling J a . If non-residential, estimated daily flow
Resiti� �ial,Commercial,Etc.
Number of bedrooms S Size of lot x �C) C)
Number of fixtures above basement �2__
Tubs,Sinks,Toilets,Etc.
Number of fixtures in basement, if any — ,
Pumped or gravity flow,
Type of water supply . If private,type of well C�
Public-Private
Information to be supplied by Health Department:
Soil type at various levels 2 4ht ryem+
'b�
Percolation rate Square effective leaching area required a A- ^,,,4i as L�a�s
fee
Size of septic tank Ir23'y Type of system
Trenches,Drywells,Etc.
Number of dry wells, trenches, etc. Distance between individual leaching
units. Distance from well on same property ca" �D ` on adjoining property 73�
Curtain drain required h�
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 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 b �'�^ 0 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 POLLUTION CONTROL
LOCATION Miller
OWNER ,�a tr Q
TYPE OF WORK
DATE -.12-76 PERMIT PIPE
INSTALLER w nip '
INSPECTOR R-P• DRAWN BY