HomeMy WebLinkAboutSeptic Repair 2504 Ellington Road �O
Town of South Windsor — Health Department Sep 24
1g40 Sullivan Avenue, South Windsor, CT 06074 S Z012
Phone: 860-644-2611 ext. 248 Fax: 860-644-7280 H C�w'/VD
N DFpT R
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM
El & A ot-,(.0&k Application/Permit
To the Director of Health,Town o£ 50 WJ9' 5())L— Date: -` r
Application is hereby made for an approval to construct a subsurface sewage disposal system for a:
91, 96h tr, ` C 1X0 G� -�4
r� (Residential Building,Restaurant,Retail Building,etc.)
located at: a �(!q -/A/6?bAI Rd. �(�vr#
(Street Address,Lot Number,Subdivision Nam ,Map,Block,Lot,etc.)
New System Addition Repair Other Owner fwd VIL&ITO Address ( 50 bWPA-1D'V PJ Tel.No0b_ /q
V7-89,51
(AwI hfNf C� Address Tel'.
QQ L t
Installer ;I YA R�' bb Cot-ynt�r� Te1.No. O�a✓�� ��17 ���
Installer License No. 0®375co'
In accordance with detailed information stated below:
Application fee paid 10.00 Signed
(Owner or duly authorized representative)
-------------------------------------------------------------------------------------------------------------------------------------
N6GENERAL INFORMATION
Soil Tests Conducted(Date): I Lot size am sq.ft.
Area of Special Concern(Y/N): If yes,Reason(s):
Basis of Design(#of Bedrooms,Restaurant Seats,Building Size,etc.):
Engineered Plan Required(Y/N): If yes,Name of Engineer:
Address of Engineer:
Design Plan Approved(Y/N): A-�_Date of Approved Plan: '1, Revision Date:
Type of Water Supply %N A If well,has location been approved(Y/N):
Well Driller's Name: Address:
OFFICE USE ONLY
Approval to Construct issued by: Jm, •\I /\"-(- Dater
(Director of Health r Registered Sanitarian)
Signature: Title:
Town of South Windsor - Health Department
Subsurface Sewage Disposal System Inspection Report
PROPERTY LOCATION: DSCH o
BOTTOM OF EXCAVATION: DATE: N INITIAL
PERCOLATION TEST "FILL CHECK": DATE: INITIAL
DEPTH HOLE# DEPTH HOLE#
TIME READING TIME READING
PERC PERC
FINAL INSPECTION: SANITARIAN DATE:
1. SEWER LINE:
A. SEWER LINE CEMENTED AT FOUNDATI (Y/N) ................PIPE LENGTH Sy
B. PITCH(.25 inches per foot min)REQUIRED LIA c '° FT................PROVIDED FT
D. PIPE TYPE&ASTM SPEC. 506,�• L�13 .................................PIPE SIZE(INCHES) L"
2. SEPTIC TANK: 15-[G Lo-t i- I Obo c ; `►
A. MANUFACTURER-Xr`C\ -mK►ob0 DATE MFD—r" r*----SIZE.CoW " " 1,2ss-1 GALLONS
B. TANK COMPARTMENTS PLACED PROPERLY(Y/N)................................................ I(
C. INLET BAFFLE(not in middle of opening). ` ..........OBSERVATION OPENING(slag removal)-&4
D. OUTLET BAFFLE FILTER TYPES RISERS NEEDED(Y/N) SIZE
E. TYPE OF PIPE (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(Y/N). ....TYPE OF PIPE
D. GREASE INTERCEPTOR TANK SIZE GALLONS........MANUFACTURER
4. D BOXES:
A. LEVEL(Y/N) SERIAL DISTRIBUTION(High level overflow within top 3")......
C. LEVEL SYSTEM(Ends tied together)(Y/N )
5. TRENCHES:
A. LENGTH OF TRENCH............ 1. 2. 3. 4. 5. 6.
B. GALLERIES(stone around all units).1. 2. 3. 4. 5. 6.
C. CENTER-TO-CENTER SPACING FILTER FABRIC PRESENT(Y/N) TYPE
D. APPROVED AGGREGATE FREE OF SILT DIRT&DEBRIS (Y/N).
F. AGGREGATE MEETS PHC SPECIFICATIONS(Y/N) TYPE OF PIPE
G. LEACHING SYSTEM DESCRIPTION:
6. SEPARATION DISTANCES CONFORM WITH APPROVED PLAN(Y/N)
STRATION DISTANCES FIELD VERIFIED (Y/N)
PASS FAIL COMMENTS:
} of- U
WELL INSPEC : SAN DATE:
WELL LOCATION Sanitary Well Cap
Rev.April 2012
FINAL INSPECTION ELEVATIONS
PROPERTY LOCATION: -S&A W f` TOWN: S, l u"ti or
PROPERTY OWNER: P�wr, G:\1❑a r k� f-
ow.\
SANITARIAN: Cl�:ln � DATE:
LEVEL TO BENCHMARK(ROD READING)
BENCHMARK ELEVATION
HEIGHT OF LEVEL.
Wilij
SEWER LINE AT FOUNDATION
SEPTIC TANK INLET
SEPTIC TANK OUTLET O
PUMP/GREASE TRAP INLET
PUMP/GREASE TRAP OUTLET
D-BOX# 1 INLET 1 G
FLOWLINE RIGHT
FLOWLINE LEFT
OUTLET
D-BOX#2 INLET
FLOWLINE RIGHT
FLOWLINE LEFT
OUTLET
D-BOX#3 INLET
FLOWLINE RIGHT
FLOWLINE LEFT
OUTLET
TRENCH # 1
RIGHT
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:
Paee 2