HomeMy WebLinkAboutSeptic Repair 185 West Road Town of South Windsor - Health Department
I640 Sullivan'AVenue,.5o.6th Windsor, CT -06074.
fir" s.4 -
-« Phone: 860-644 2511 ext. 248 fax. 860.644-7280
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM
ApplicationtPermit#:
To the Director.ofHealth,Town of: t,� ) .�/{ ) S jam" Date: ���;� �
Application is hereby made for an approval to construct it subsurface.sewage disposal system for a:
c (Residedtial Building,.Restaurant,Retail Building,etc.)'
located at
(Street Address,Lot Number,Subdivision Name;.Map,Block,Lot,etc.)
New System . Addition Repair Other.
i
Owner r c�t,,'n t'i\ Address_ 1 Vim. IAA Z5 � Tel:No.
Installer Van f, Address�'�ilr TeI.Nof �.1
T Installer License No. 3
In accordance with detailed information stated'below:
r
Application fee paid I Signed
(Owner or duly.authorized representative)
GENERAL INFORMATION
Soil Tests Conducted(Date): A �IT. Lot size sq.ft.
Area of Special Concern 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: REE+�E'�/ED
JUL 27 2015
SOUTH WINDSOR .
HEALTH DEFT.