HomeMy WebLinkAboutPermit to Discharge New 123 Windsorville Town of South Windsor — Health Department
_ 1640 Sullivan Avenue, South Windsor, CT 06074
nary Phone: 860-644-2511 ext. 248 Fax: 860-644-7280
PERMIT TO DISCHARGE
Approval is hereby given to 5��,�,,�� a \M`s�.`��CjunbS in accordance with Public
(Property Owner)
Health Code Section 19-13-B103e(h)to discharge to a subsurface sewage disposal system located at
(Street Address)
in the town of S „ i ��SQ{- ,CT that will receive domestic sewage from a:
Residential building containing L-A bedrooms. Single family(Y/N):
Restaurant containing seats.
Commercial/Office building providing square feet.
Other structure as described:
Design Flow= _gallons per day. Permitted Flow=��� gallons per day.
The design flow shall equal the permitted flow,except for non-compliant repairs(See Section IV D).
In order to provide a sufficient factor of safety it is recommended that the average daily discharge not
exceed 2/3 of the permitted flow or 2n 6 gallons per day.
Operation and Maintenance: Septic tank shall be inspected regularly and pumped as needed but not
less frequently than every five years. The septic tank has an effluent filter(Y/N)_( . Effluent filters
require periodic cleaning. Failure to clean filters can result in sewage backup into the building or effluent
breakout. Restaurants serviced by external grease interceptor tank(s)require quarterly inspections and
cleaning as necessary. Tank pump-outs tracked by local health department(Y/N) If yes,
stipulate pump-out requirements:
Special Requirements and Restrictions: 1.In the future, if there is a septic system malfunction or
failure it must be addressed.
Exceptions(Repairs Only):
File Information: Construction Permit No. Approved as-built on file(Y/N)
Date of Final Inspection: -L_ Inspected By: cS'( u("A w.nr
Permit Issuance: Issued by: Title: G-y= _JACJ\�, Cr
(Director of Health 4 Registered Sanitarian)
Signature: Date: qlgL�
' R.. PIPPIN & SON INC. �3 �2 ce
:� _: (888)870-5015
(860)623-2313
!' RECEIVED
APR 2 5 2012
SOUTH WINDSOR
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T.-;ff 2v�> 6r l
1
APPROVE
TOWN OF SOUTH WINDSO
HEALTH DEPARTMENT
DATE:
SIG:
PLEASE SIGN HERE: PLEASE READ TERMS&CONDITIONS ON SACK
j
FINAL INSPECTION ELEVATIONS
PROPERTY LOCATION: 1;Q-3 �.�iLs;�c.,:���_Clk TOWN: �Z. Wiy ,c ,cc�r
PROPERTY OWNER: S - , S� �h&,,r 1wAU- Ck
INSTALLER: V;
SANITARIAN: DATE:
LEVEL TO BENCHMARK(ROD READING) I S I
BENCHMARK ELEVATION %pQ
HEIGHT OF LEVEL. I C) r . S 1
SEWER LINE AT FOUNDATION
SEPTIC TANK INLET q, gs
SEPTIC TANK OUTLET
PUMP/GREASE TRAP INLET ,
PUMP/GREASE TRAP OUTLET
D-BOX# 1 INLET
FLOWLINE RIGHT 4
FLOWLINE LEFT ,
OUTLET 6 . 1
D-BOX#2 INLET (�
FLOWLINE RIGHT 8,03
FLOWLINE LEFT C)
OUTLET
D-BOX#3 INLET
FLOWLINE RIGHT
FLOWLINE LEFT
OUTLET
TRENCH # 1
RIGHT a , n
LEFT
TRENCH # 2
RIGHT
LEFT
TRENCH # 3
RIGHT
LEFT
INVERT ELEVATION=Top of Pipe+Diameter of Pipe—Height of Level
HEIGHT OF LEVEL=Benchmark+Rod Reading
Reference:
Page 2
Town of South Windsor — Health Department
Subsurface Sewage Disposal System Inspection Report
PROPERTY LOCATION: 1233 &'1—
BOTTOM OF EXCAVATION: DATE: J'V Vk INITIAL
PERCOLATION TEST "FILL CHECK": DATE: N INITIAL
DEPTH HOLE# DEPTH HOLE#
TIME READING TIME READING
PERC PERC
FINAL INSPECTION:SANITARIAN �0 � s�-,o,nr�. DATE: L4j-a<-),
�c o r� ovr el �� - IS '
1. SEWER LINE:��:� Sl,.a-o e�,.;.s} -
A. SEWER LINE CEMENTED AT FOUNDAT O (Y/1� ram_................PIPE LENGTH 10. 8
B. PITCH(.25 inches per foot min)REQUIRED 'a."3 FT................PROVIDED -3•4$ FT
D. PIPE TYPE&ASTM SPEC. Scat,�-AD .............PIPE SIZE(INCHES)
2. SEPTIC TANK:
A. MANUFACTURER c ep— DATE MFD a U O1 SIZE. GALLONS
B. TANK COMPARTMENTS PLACED PROPERLY(Y/N)................................................ y _
C. INLET BAFFLE(not in middle of opening). .........OBSERVATION OPENING(slag removal) �
D. OUTLET BAFFLE FILTER TYPE RISERS NEEDED(Y/N) IV SIZE
E. TYPE OF PIPE S D(K (approved by code)
3 PUMP CHAMBER/GREASE TRAP:
A. PUMP CHAMBER MANUFACTURER ...SIZE GALLONS
B. TYPE PUMP ............PUMP ALARM CHECKED (Y/N)
C. FLOAT CONTROL ELEVATION VERIFIED . .....TYPE OF PIPE
D. GREASE INTERCEPTOR TANK SIZE GALLONS........MANUFACTURER
4. D BOXES:
A. LEVEL(Y/N) y SERIAL DISTRIBUTION(High level overflow within top 3")....... A—
C. LEVEL SYSTEM(Ends tied together)(Y/N)
5. TRENCHES:
A. LENGTH OF TRENCH............ 1. 104 � 2. 1 OBI _
' 3. 4. 5. 6.
B. GALLERIES(stone around all units).1. 2. 3. 4. 5. 6.
C. CENTER-TO-CENTER SPACING Y _ FILTER FABRIC PRESENT TYPE •
D. APPROVED AGGREGATE FREE OF SILT DIRT&DEBRIS(Y/N). _
F. AGGREGATE MEETS PHC SPECIFICATIONS (Y/N) Y __ TYPE OF PIPE S` L- ',:�
G. LEACHING SYSTEM DESCRIPTION: 10;.spa z � - \� S�S�►Cv`
ti
6. SEP TION DISTANCES CONFORM YnM APPROVED PLAN(Y/N)
SE RATION DISTANCES FIELD VERIFIED (Y/N)
PASS FAIL COMMENTS: ` C Ds., \ QQ MS •\h Su'�Ln M111—am
lbl-
WELL INSPECTION: SANITARIAN DATE:
WELL LOCATION Sanitary Well Cap
Rev.April 2012
Town of South Windsor — Health Department
1540 Sullivan Avenue, South Windsor, CT 06074-2786
Phone: 860-644-2511 ext. 248 Fax: 860-644-7280
APPROVAL TO CONSTRUCT OR REPAIR SEWAGE DISPOSAL SYSTEM
Approval is hereby granted for the construction/repair of a subsurface sewage disposal system
at the property described below:
PROPERTY OWNER(S): Shawn&Michelle Clemons
STREET ADDRESS: 123 Windsorville Road TOWN:South Windsor
INSTALLER: Richard P.Pippin CT.LIC#001061 EXPIRES: 01/31/2013
RESIDENTIAL: #of Bedrooms- 4
INSTRUCTIONS FOR INSTALLER
1. Construction plot plan submitted and approved by this office must be adhered to.
2. This office must be contacted for approval if any change is going to be made in the system
location,size or design,or any changes in house,well or property line locations.
3. Any NEW sewage disposal system must conform to ALL requirements of Section 19-13-BI03 of the CT
Public Health Code.
4. ALL new construction to be under DIRECT supervision of a CT licensed installer under Section
20-341 of the CT General Statutes.
5. The installer is RESPONSIBLE for VERIFYING LOCATIONS of PR OPER TY LINES, WELLS,
and BURIED UTILITY LINES prior to construction.
6. Installer to notify South Windsor Health Dept.24 hours prior to the start of construction.
7. Installer to have septic tank covers removed at the time of inspection.
SPECIFIC INSTRUCTIONS:
1. Install per approved plan, (Pippin &Son, Received: 04/19/2012).
2. Licensed Installer to field stake house, well (if applicable), permanent benchmark, and septic system. Offset stakes
to include, bottom of trench or flow line elevations. Health Dept. staff to conduct stake inspection prior to
construction of system.
3. Permanent benchmark to be set within 50 feet horizontally and 12 feet vertically of septic system.
4. Install a 1,250 gallon two compartment septic tank, with an approved outlet filter. Risers are to be installed if there
is to be more than 12"cover over septic tank cleanouts.
5. Install 660 square feet of effective leaching area-a level system, consisting of 2 rows of 3 foot wide by 18-inch high
stone trenches, 100 feet long, with a d-box in the middle and the end of the trenches tied together. Center to center
spacing of trenches shall be a minimum of 7 feet.
6. Max depth into existing grade is not to exceed sixty six(66) inches.
7. Installer to schedule, and be present for final inspection with Health Dept. staff. Level to be set up for verification of
elevations OR an engineer's/surveyor's as built will be required.
8. Installer to complete and submit septic system as built plan and drawing with ties to the house.
9. Existing septic s stem to be properly abandoned.
SIGNATURE: ATE ISSUED: 04/19/2012 RENEWAL: 1 1
APPROVED BY: Sherry M ann EXPIRES: 04/19/2013 EXPIRES: 1 1
THIS PERMIT IS VALID FOR A PERIOD OF ONE YEAR FROM DATE OF ISSUE. IN ACCORDANCE WITH THE CT PUBLIC HEALTH CODE
SECTION 19-13-BI03e(F)(1). ONE RENEWAL IS POSSIBLE PROVIDED SOUTH WINDSOR HEALTH DEPARTMENT IS NOTIFIED PRIOR TO
THE EXPIRATION DATE NOTED ABOVE. IF PERMIT EXPIRES, INSTALLERS ARE CHANGED, OR ANY OTHER DEVIATION FROM THE
ORIGINAL PERMIT,A NEW APPLICATION MUST BE COMPLETED AND ALL APPLICABLE FEES MUST BE PAID.
FEE PAID:10.00 CHECK# 19534 DATE PAID:04/19/2012
Town of South Windsor — Health Department
1640 Sullivan Avenue, South Windsor, CT 06074
Phone: 860-644-2611 ext. 248 Fax: 860-644-7280
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Application/Permit#:
To the Director of Health,Town of LV't Date: 0 V—
Py-
Application is hereby made for an approval to construct a subsurface sewage disposal system for a:
Rt�SE`�0nC,(V
(Residential Building,Restaurant,Retail Building,etc.)
located at: �3 1��h�S Q f✓�`�f n Rj
(Street Address,Lot Number, Subdivision Name,Map,Block,Lot,etc.)
New System Addition Repair Y Other
Owner C I� e WD v7 S Address 123 c%�d sdn��I�(���T�1 No. 1136 C//O.? ^ C r,f
,`c-
Installer � y IJ p RiAq,`( Address_3'1/t�i'.V/g►,9 Te1.No. 00 (0 2,3 2Ak
Installer License No.
In accordance with detailed information stated below:
Application fee paid L 5' Signed d&,en-�p
(Owner or duly authorized representative)
-------------------------------------------------------------------------------------------------------------------------------------
GENERAL INFORMATION
Soil Tests Conducted(Date): 4L� Lot size .IS , 9 11-720 sq.ft.
Area of Special Concern(Y/N);_ f yes,Reason(s):
Basis of Design(#of Bedrooms,Restaurant Seats,Building Size,etc.):
Engineered Plan Required(Y/N): /V If yes,Name of Engineer:�Jl
Address of Engineer:
Design Plan Approved(Y/N): ' Date of Approved Plan: Revision Date:
Type of Water Supply P"At If well,has location been approved(Y/N): �jl gr
Well Driller's Name: r\ P' Address: ���TTT�
OFFICE USE ONLY
Approval to Construct issued by: A ,,n y� Date:
(Director of Health or egistered Sanitarian)
Signature: Title: ,� � Q/
Squth Windsor Online Property Viewer Page 1 of 2
Town of South Windsor, CT Property Record Card
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Property Information
Parcel ID 95700123
Address 123 WINDSORVILLE ROAD
Owner CLEMONS SHAWN G
Owner Address 123 WINDSORVILLE RD
City State Zip SOUTH WINDSOR, CT 06074
Sale Date 4/2/2003
Book/Page 1437336
Census Tract 4871
Valuation
Assessed Value $175,140.00
Zone Code RESIDENTIAL A-20
Primary Land Use RESIDENTIAL LOT
Building Information
Year Built 1965.000000
Style 1 E
Roo 7.000000
Total Area 0.000000
http://host.appgeo.com/SouthWindsorCT/PropertyRecordCard.aspx?PropertyID=95700123 4/16/2012
South Windsor Online Property Viewer Page 2 of 2
Water Code PUBLIC WATER
Sewer Code
Gas Code
Lot Information
Area Acres 0.50
Sq Ft 21780.00
Date Printed:4/16/2012
http://host.appgeo.com/SouthWindsorCT/PropertyRecordCard.aspx?PropertylD=95700123 4/16/2012
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PLEASE SIGN HERE: PLEASE READ TERMS&CONDITIONS ON BACK
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' Town of South Windsor — Health Department
` 1540 Sullivan Avenue, South Windsor; CT 06074
Phone: 860-644-2511 ext. 248 Fax: 860-644-7280
SITE INVESTIGATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Application/Permit#:
Property Owner kNpt �< Location
DEEP TEST PIT DATA/SOIL DESCRIPTIONS
DATE: (Record all Test Pits)
TEST PIT: TEST PIT: TEST PIT: TEST PIT:
�—•LA
Mottles: Mottles: Mottles: Mottles:
GW: tj 10 GW: GW: GW:
Ledge: 0 10 Ledge: Ledge: Ledge:
Roots: to Roots: Roots: Roots:
Restrictive: 114 Restrictive: Restrictive: Restrictive:
COMMENTS:
GROUNDWATER TABLE(Near max.,below max.,etc.): �.�.5
SOIL MOISTURE(High,medium,low,etc.):
PERCOLATION TEST DATA
DATE: t, n., (Record all Perc Tests)
PERC: PERC: PERC: PERC:
DEPTH: B0 DEPTH: DEPTH: DEPTH:
PRESOAK: Y16 PRESOAK: PRESOAK: PRESOAK:
TIME READING TIME READING TIME READING TIME READING
lm5b Lt.S
(0- 52 toy`
to: ” I-)
PERC PERC PERC PERC
RATE: RATE: RATE: RATE:
COMMENTS:
SITE INVESTIGATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
LOCATION DRAWING INCLUDING ALL TEST PITS AND PERCOLATION HOLES
C'
ClTPI
SPECIAL CONDITIONS CONCLUSIONS
Design Flow>2000 GPD Suitable for Sewage Disposal
Public Water Supply Watershed Unsuitable for Sewage Disposal
Probable High Groundwater Additional Investigation Req'd
Slope>25 percent Wet Season Monitoring Req'd
Perc Rate< 1 min/inch Retest During Wet Season
Perc Rate>30 min/inch Licensed Engineer Plan Req'd
Ledge<5 feet below grade Other:
Limited Suitable Area
Open Watercourse or Wetlands
Flood Plain/Seasonal Flooding
Max.G.W. <36 inches below grade
DESIGN RECOMMENDATIONS/COMMENTS
Form completed by: oy �/�\C��G„r•nn
Certified Lo al Health Agent or P.E.)
Accuracy assured by(If P.E.completed form): N�
(Certified Local Health Agent)
Others present for site investigation(Engineer,developer,installer etc.):
Town of South Windsor — Health Department
L 1540 Sullivan Avenue, South Windsor, CT 06074-2786
Phone: 860-644-2511 ext. 248 Fax: 860-644-7280
DESIGN RECOMMENDATIONS FOR REPAIR OF SEWAGE DISPOSAL SYSTEM
PROPERTY OWNER(S): Shawn Clemons
STREET ADDRESS: 123 Windsorville Road, South Windsor
RESIDENTIAL(#of Bedrooms): 4
SEPTIC TANK: Install 1,250 gallon two-compartment septic tank with approved outlet filter.
LEACHING SYSTEM: 660 square feet of effective leaching area required.
Maximum Depth into original grade is not to exceed sixty-six(66)inches.
Minimum Leaching System Spread(MLSS)need not be addressed due to soil conditions(>60"to restrictive).
SPECIFIC INSTRUCTIONS:
1. Permit application to be completed and permit fees to be paid in full at time of application submission.
2. Installer's construction plot plan(drawn to scale)to be submitted and approved by this office prior to
issuance of permit to construct.
3. Plot plan must indicate location of proposed structure,water supply, septic system, embankments,
watercourses,property lines, and existing and proposed finished grades. Benchmark to be set and indicated
on plan. Note on plan that existing Septic System is to be properly abandoned.
SIGNATURE: DATE: Il b j'L
SITE INVESTIGATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
LOCATION DRAWING INCLUDING ALL TEST PITS AND PERCOLATION HOLES
kv
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DTP 1
SPECIAL CONDITIONS CONCLUSIONS
Design Flow>2000 GPD Suitable for Sewage Disposal
Public Water Supply Watershed Unsuitable for Sewage Disposal
Probable High Groundwater Additional Investigation Req'd
Slope>25 percent Wet Season Monitoring Req'd
Perc Rate< 1 min/inch Retest During Wet Season
Perc Rate>30 min/inch Licensed Engineer Plan Req'd
Ledge<5 feet below grade Other:
Limited Suitable Area
Open Watercourse or Wetlands
Flood Plain/Seasonal Flooding
Max.G.W.<36 inches below grade
CL DESIGN RECOMMENDATIONS/COMMENTS
Form completed by: `'I`Q C Mrs
Certified Lo al Health Agent or P.E.)
Accuracy assured by(If P.E.completed form):
(Certified Local Health Agent)
Others present for site investigation(Engineer,developer,installer etc.):