HomeMy WebLinkAboutSeptic Repair 429 Griffin Road Town of South Windsor - Health Department
�% 1640 SuilivanAvenue,South Windsor, CT -06074
Phone: 860-644-2511 ext. 248 fax: '860 6444280 -
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Applical on/Permit#:
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Town of: (�� Date: - 45 `S
Application is Hereby made for an approval to construct:a subsurface.sewage disposal system for a
(Residential Building,Restaurant;Retail Building,etc.)
located at. .� ✓r
(Street Address,Lot Number,Subdiwtsion Namm ;Map,Block;Lot,etc.)
New System Addition Repair l/ Other.
Owner 1 � ,r
f �,��C- �1.r �t�/�Address Te1.No.
Installer TT? 1 �� .�v v�S Address_ .S'. tom:, !s ,� Tel.No.
Installer.License No_�� e9 2 8 s �/3
In accordance with detailed information stated below:
_ Application fee paid Signed
Owner or duly authorized representative)
GENERAL INFORMATION
Soil Tests Conducted(Date): Lot size sq.ft.
Area of S ecial Concern,;�<�i�:Gy/h <<K (�i✓ �� `�
p (Y/N): If yes,Reason(s):_-
Basis ofDesign(#of Bedrooms,Restaurant Seats,Building Size;etc.): UY � ��`S
Engineered Plan Required. G? .lie �g q (Y/I�: Ifyes,Name of Engineer: `
Address of Engineer:
Design Plan Approved(Y/N): Date of Approved Plan: Revision Date:
Type of Water Supply If well,has location:been approved(Y/N):
Well Driller's Name: Address:
OFFICE USE ONLY
Approval to Construct issued by: Date:
(Director of Health or Registered Sanitarian)
Signature: Title: