HomeMy WebLinkAboutSeptic Repair 1164 Pleasant Valley Road SOU;'H WINDSuR
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Ft . s SOUTH WINDSOR HEALTH '2• Investiact-ou.;or �. nge Oispoaar.. 3YsZ
DEPARTMENT
VM= COEDIT 0113 .
System deaig;t larger than 21000 g.p.d. Water supply -Ztershad
mtgh around water (less than 44 't.) Possible seasonal, high
ground water
sraterccurae, marsh or pond Possible seasonal Aoadiag
kited suitable srea Slope over ISZ•-
Margiaal soil (30 - 60 0111=4inch) Shall ov ledge (loss than T ft.)
=denying tight soil (less tbsa 4 ft)_ Other
COI9CZI1 Cw
Suitable for sewage disposal
=suitable for sewage disposal
Additioaal investigation required
.Retest during vet season
*r's plea required .
D=GN RMORMMATI01M
Iavestigated by Title
Coati:�ed/Witnessed by `
comments:
Benchmark location e^levsition
TOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT '
Application for permit to install ar"epair subsurface sewage disposal system. To the Health Department,
Town of South indsor.
Fee Paid Date Permit Number
Asp a, subsurfa sewage dispos I system in ller I'cens d in the Stat of 2n e�cticut, I
Nam Address, Telephone Number, �� License Number
here y L p for a pefmit to onstr tl pair a subsurface sewage disposal syVeln located at
and owned by
Street, Address, Lo Number Name
f
Address
Information to be suppli-ed by Aj licari : J
Type of dwelling I . If non-residential, estimated daily flew
Residential,Commercial,Etc.
Number of bedrooms I 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 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
Curtaip drain required
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 by Date zi
tfature of Applican &License Number.
Fo'rOffice Use Only
Permit issued by !Date:
System installed by
Final Inspection Approval mate
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NOTES SOUTH WINDSOR HEALTH DEPARTMENT
LOCATION !/ 6 4 rkta i/&/Avy
OWNER
TYPE OF WORK l2eiglace av%& 0
DATE 8- - PERMIT PIPE
INSTALLER
INSPECTOR DRAWN BY
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