HomeMy WebLinkAboutSeptic Repair 51 Wendy Drive 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 C� � f j l Date b Permit Number
9a,-_a subs�urf�ce, sewage dis�osa system installer licensed n the State of Conner c ' ut,I
Name, Address, Telephone Number, License Number
hereby apply for permit to construct/repair a subsurface sewage disposal system located at
, ' and owned by
Street, Address, W Number Name
Address
Information to be suppliedby A pli ant•
Type of dwelling //oL'.S', i�., , . If non-residential, estimated daily flow
Residential,Cmmercial,Etc.
Number of bedrooms 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
Curtain 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 //✓
S nature of Applicant 911cense Number
For Office Use Only
't issued by Date
'Mailed by
,ection Approval Date
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SOUTH WINDSOR HEALTH DEPARTMENT
746 fc LOCATION S l w
OWNER
TYPE OF WORK
__DATE__ -. --0-0 PERMIT _ PIPE-
INSTALLER we
INSPECTOR DRAWN BY
FORM #3 State of Connecticut Department of Public Health APPLICATION NO.
CHECK LIST
REVIEW OF PLAN/INSPECTION OF SEWAGE DISPOSAL SYSTEM
Owner Location &." Date Rec'd
Plan prepared by Title Address
Site Investigation Investigated by
(Date)
Bench mark location Elevation
Design Percolation Rate Mins./inch at hole(s)
If residential,number of bedrooms If non-residential,estimated daily flow
HOUSE SEWER(INVERT LEVELS)
Depth s /a
Depth at foundation wall ,�3 D eP at septic tank
SEPTIC TANK
5 -e as bw,%11 Ct�-�rK5
Cleanout located ft.from and ft.from
Manufacturer P t-C16 T Size (a-S�y gals. Depth to cleanout
LEACHING SYSTEM
Description
Effective area sq.ft. Required effective area sq.ft.
Spacing between units ft. 100%reserve area provided AM
Bottom of leaching system 18 inches above maximum water table
Bottom of leaching system 4 feet above ledge rock
Bottom of leaching system '/ inches below final grade.
Pumping required / Curtain drain required n v
P g re q `L O
Serial distribution Y e S Level system
SEPARATING DISTANCES
Well Located v bjtc- ft.from and ft.from
Distance sewage system to well on property ft. To water service ft.
To well on adjacent property 4/_Ia ft. To property line ft.
To house served /S� ft To dwelling adjacent property !°O ft.
To nearest watercourse /r/ ft.. To nearest ground or surface water drain ft.
Reviewed/inspected by Title
PLAN/INSTALLATION APPROVED DATE
INSPECTION FEE PAID
I/l/00
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