HomeMy WebLinkAboutSeptic Repair 80 Windsorville Road -FORM-#2 State of Connecticut Department of public Health APPLICATION NO.
INVESTIGATION FOR SEWAGE DISPOSAL SYSTEM
Owner
Location
�,,s�ls � c�
b.
PERCOLATION TESTS:(Record all Tests) 02 SOIL MOISTURE:_ (Date) (high,med.,low,etc.)
TEST READINGS
HOLE HOLE
. .HOLE HOLE ea g une ea g une 9.
une g une
TABULATION OF TEST RESULTS Percolation Rate
Hole Location -
Depth Presoak Time
OBSERVATION PETS:(Record all pits) _�-'2.t o Groundwater Table-
(ate) (Near max.,.Belowmax:,etc):: .
SOIL DESCRIPTIONS
L--71
PIT
PIT.. PIT.
ad, uc ¢ 0ha1
TABULATION OF TEST RESULTS Ground Water Mottling
Pit Location Depth Ledge
M100
49
1 55 '
L
q4
r-<1/0n
L �a
b )4 g4c, 1 35 Q-koi�- y�7 ' a `' fG s 37
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 Date Permit Number
As a subsurface sewage [,�di�sposal system installer licensedd in the State of Connecticut, I
ttu
Name, Address, Telephone Number, License Number
hereby apply for a permit to construct/repair a subsurface sewage disposal system located at
Sb 4V/4d_r-&.vf L Rd and owned by X"f c rw
Street, AdddQdress, L t Number Name
/�tlt
Address
Information to be supplied by Ap lica t:
Type of dwelling t�g'S V n ,�, If non-residential, estimated daily flow
Residential,Commercial,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 C�tz�,�l L If private,type of well
blic-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 / dLl 0
n ture of Applicant&License Number
For Office Use Only
Permit issued by Date
System installed by
Final Inspection Approval Date