HomeMy WebLinkAboutSeptic Repair 216 Smith Street TOWN OF SOUTH WINDSOR
LTH DEPARTMENT
Application for permit to install a ne r pa• subsurface sewage disposal system. To the Health Department,Town of SclUth Windsor.
Fee Paid It /0 °Q� Date Permit Number
As a suA-4lo-rik
surface sewage dispo I *V1nstaller I�ensed,.i the Mate of Connecticut, 1
2/6 .fir, c �Q-!l!O d
Name, Address,
Telephone Number, . License Number
hereb appl for a p rmit to construct/repair a subsurface sewage dis os I s s em located at
2./9 sm' rr[ and owned by or;
Street, Ad ress, Lot N ber
Name
Address
Information to be supplied by Applicant:
Type of dwelling cr If non-residential, estimated daily flow
Residential,Commercial,Etc.
Number of bedrooms 3 Size of lot kx Ac.
Number of fixtures above basement y
Number of fixtures in basement, if any IVewdcd
Tubs,Sinks,Toilets,Etc.
_
'�
Type of water supply p y/V � If private,type of well Pumped or gravity flow,
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
Number of dry wells, trenches, etc. 41 has,Drywells,Etc.
Distance 9tween individual leaching
units. Distance from well on same property on adjoining property
Curtain drain required
Yes,No
Height of system above ground water maximum groundwater
[edge 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 JSignatureo4fApplicDate ! r� b
&License Number
For Office Use On.ly...
Permit issued by Date
System installed by
Final Inspection Approval Date 23 44
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w// I �Zs n K
SNOTES OUTH WINDSOR HEALTH DEPARTMENT
LOCATION /6 rwvAA
OWNER
TYPE OF WORK
DATE -13 6 PERMIT PIPE
INSTALLER k r -
INSPECTOR DRAWN By