HomeMy WebLinkAboutSeptic Repair 14 Graham Road Town. of South Windsor --Heath Department
1640 Sullivan Avenue,South Windsor, CT 06014-
s ' ` `Phone: 860-644=2611 ext:248 Fax: 860=6444280
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE.SEWAGE DISPOSAL SYSTEM
Application/Permit#
To the.Director of Health,Town of..rr1-t I PS Date: c�43
Application is hereby made for an approval to.construct it subsurface:sewagedisposal system for x
(Residential giulding,.Restaurant,Retail Building,etc:14
).
located at: .0 ~t 'ppo
(Street Address,Lot Number,Subdivision Name;Map,Block,Lots etc.).
New System Addition Repair Other .
Owner Address
TelNo
Installer IS 1 i1 f 9A Address P( � �Wel.No.
Installer License No.
In accordance with detailed information stated below:
Applicatiom.bee paid Signed
(Owner or duly authorized representative)
GENERAL INFORMATION --- ---
Soil Tests Conducted(Date): Lot size : sq.ft.
Area of Special Concern(Y/N): If yes,Re-ason(s):
Basis of Design(#of Bedrooms,Restaurant Seats,Building Size,etc.):
Engineered Plan Required(YIN): If yes,Name of Engineer:
Address of Engineer:
Design Plan Approved(YIN):: Date of Approved Plan: Revision Date:
Type of Water Supply If well;has.location been approved(Y/N):
Well DrUler's Name: Address:
OFFICE USE ONLY
Approval.to Construct issued by: Date:
(Director of Health or Registered Sanitarian)
Signature: Title:-