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HomeMy WebLinkAboutSeptic Repair 465 Main Street 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 )j) Application/Permit#: To the Director of Health,Town of: SC gyhh W ei n Date: 10 MA`f j Z Application is hereby made for an approval to construct a subsurface sewage disposal system for a: CN;n " esidential Buildinp Restaurant,Retail Building,etc.) located at: (Street Address,Lot Number,Subdivision Name,Map,Block,Lot,etc.) New System Addition Repair Other Owner IE f 0j C .a Address a=Ste]li.,kh Av t— Te1.No. V,JAcl � 1 Installer V�r NS Saw- +G Address Tel.No. Installer License No. (31 K6 In accordance with detailed information stated below: Application fee paid 1 0.00 Signed (Ownef or duly authorized representative) GENERAL INFORMATION Soil Tests Conducted(Date):-W t I?g Qm-�4�Lot size 1.C/Mtrc,-� ©33 sq.ft. Area of Special Concern(Y/N): If yes,Reason(s): Basis of Design(#of Bedrooms,Restaurant Seats,Building Size,etc.): Jr �r ems Engineered Plan Required(Y/N):_NIf yes,Name of Engineer: Address of Engineer: Design Plan Approved(Y/N): Date of Approved Plan: to -L- Revision Date: Type of Water Supply Q , If well,has location been approved(Y/N): Well Driller's Name: N I99 \:�hr- Address:_ Nix OFFICE USE ONLY Approval to Construct issued by: V y� a Date: b (Director of Hea or Registered Sanitarian) Signature: Title: cv. 1� r. � cel