HomeMy WebLinkAboutApplication 35 Oakland Road ° `°=M�C Town of South Windsor - Health Department
o � 1540 Sullivan Avenue, South Windsor, CT 06074
'�•,.
SON Phone: 860-644-2511 ext. 250 Fax: 860-644-7280 /� �z 3�/6
q c"'
a
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM
(� Application/Permit#:
To the Director of Health,Town �I: \flUl .% UY Date: �� 3
1.0
Application is hereby made for an approval io construct a subsurface sewage disposal system for a:
f �' < o d iL C'e5.
� (Residential Building, Restauran et it Building,etc.)
located at: ✓ &� / k 'q�- 401
(Street Address,Lot Number, Subdivision Name,Map,Block,Lot,etc.)
New System ` I 11Addi�tionn Repair Other
Owner J W V` ��-E� Address UV�° �ci Te1.No.
Installer 1 11,��k S Address �7 1_th\k j( q— Tel.No. �/ 7
Installer License No. -5 �7`{ 7
In accordance with detailed information stated below:
Application fee laid It 10 rash Signed
(Owner or duly authorized representative)
GENERAL INFORMATION
Soil Tests Conducted(Date): 1.ot ,izc 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 (' 1
Approval to Construct issued by: J bes l(,Q�J Date: l 2O I
(Director of Health or Registered Sanitarian)
Signature: r ``� �•+S Title: V
i
I
li
I
I
I
�� ,
_��Q ���� �� �
t� ���
� ��� � � \
�� �
�� ,'�
✓�
.S�