HomeMy WebLinkAboutSeptic Repair 383 Deming Street Town of South Windsor - Health Department
1540:SuI11van Avenue,South Windsor, CT -06074;
Phone: 860-644-2511ext. 248` Fax. 860-6444280
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Application/Permit#.
To the Director of Health,Town of. pjij Date:
- � -S-. .
Application is hereby made.fbran approval to:construct.a subsurface sewage disposal system for a.
(Residential Building,:Restaurant;Retail Building,etc..)
located at. gIn �. .�
(Street Addr s,Lot Number;gubdivision Name;Map,:Block,Lot etc:)
New System Addition - Repair Other
Owner- U Te1:No _J�
Installerais
?d�S Address •® S' Tel.No.&0�9
Installer License No.
Til accordance with detailed information stated below:
Application fee paid ":: 00
Signed
r d orized representative)
GENE IINFO TIO
Soil Tests Conducted(Date): Lot size 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):. 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: