HomeMy WebLinkAbout90 Foster Street Form#3 Technical Standards for Subsurface Sewage Disposal Systems 1/1/11
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Application/Permit#:
z Final Inspection Report
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Local Health Department:
Property Owner:
Property Address: qy po S Town:
Licensed Installer: License#:
Approved Plan Information
Check one: New System ✓❑ Repair/Replacement System
Residential Building: bedrooms Large Tub: YES NO Garbage Disposal: YES NO
Non residential Building/Residential Institution: GPD
Plan Prepared by: Title:
Plan Approved by: Date:
Approval to Construct
Date Permit Issued: Permit Issued by:
Registered Sanitarian or Director of Health
Inspection Information
Licensed Installer
Type Date Present? Yes/No Comments
Field Stake Inspection(house,
well,property lines,system etc.)
Strip/Scarification
Sieve required(Yes/No)
Select Fill Placement
Other:
Final Inspection
Was 24 Hour(min)Installer Notice Given(Y/N): Date Final Inspection Requested:
Date of As-Built
Final Inspection Completed by: Approval:
Permit to Discharge Issued by: Date:
Registered Sanitarian or Director of Health
FORM#3 (Cont'd) Technical Standards for Subsurface Sewage Disposal Systems 1/1/11
Final Inspection Report
House Sewer Information
Pipe Type and ASTM Specification: Pipe Size: yr in.
Pipe Invert Elevations at: Pipe Length: t1 ft.
Foundation Wall: Pitch Required:
Septic Tank: Pitch Provided: .S
Tank Information
Septic Tank Size: Gallons Tank Inlet Elevation:
Tank Manufacturer: Tank Outlet Elevation:
Date Manufactured: Riser Needed(Y/N):
Outlet Filter Type/Manufacturer:
Pump Chamber
Size: Gallons Pump Alarm Checked(Y/N):
Pump Chamber
Manufacturer: Float Control Elevation Verified(Y/1):
Grease Interceptor Grease Interceptor Tank
Tank Size: Gallons Manufacturer:
Leaching System Information
Approved Aggregate: Free of silt dirt and debris(Y/N): Sieve Required(Y/1):
Filter Fabric Present(Y/N): Type: Aggregate Meets PHC Specifications(Y/N):
Select Fill(Y/N):_ Meets PHC Specifications(Y/1): Sieve Information on File(Y/N):
Leaching System Description(product,size length,number of rows level or serial etc.):
Effective Leaching Area Required: sq.ft. Reserve Area Provided(N/A,Y/N):
Effective Leaching Area Provided: sq.ft. Center to Center Spacing: ft.
System Installed Per Approved Plan Elevations(Y/N): Elevations Field Verified(Y/N):
Elevation notes:
Separation Distances
Separation Distances Conform with Approved Plan(Y/N):
Separation Distances Field Verified(Y/N):
"� � Town of South Windsor — Health Department
1540 Sullivan Avenue, South Windsor, CT 06074
�
,, Phone: 860-644-2511 ext. 250 Fax: 860-644-7280'
SEPTIC SYSTEM AS-BUILT PLAN
Date' I - Permit Number
Street Address !U
New Septic System Repair of Septic System Alteration of System
Number of Bedrooms OR Design Flow of Building
Type of System
Installed
(e.g.stone trenches,infiltrators,galleries etc.)
Square Footage of System: Total Length Width
Effective Leaching
Area ]
Capacity of Tank C' I I 6 s Tank: New _ Existing
Length of House Sewer Pipe
Minimum Distance Between Septic Tank &Foundation
Minimum Distance Between Leaching Field&Foundation
Minimum Distance Between Sewage System&Nearest Well S
Public Water Supply
Minimum Distance Between Leaching System and Property Boundary
Curtain Drain Required? 9 y
Minimum Distance From Leaching System to drains
(curtain,foundation,storm water,etc.)
r'
***DRAFT DRAWING ON REVERSE SIDE OF FORM
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1
r
SEPTIC SYSTEM AS-BUILT PLAN (continued)
Address ��� � �� Date C
Location of System
oLrt` side of house
(N.S.E.W.,Front,Back)
Draft a substantially correct drawing showing separation distances of septic system insallation.
Include all of the following information to provide an accurate record of the entire system
location:
At least two sides of the building nearest the system,septic tank,house sewer,
distribution boxes,trench ends,dry wells,curtain drain,potable water supply wells,and any
other features affecting the system and its location.
Installer's Name "/ + s bc-1 License#
G,/
Installer's Address � S U C�c. n �� ' 30. ,1 d5
d'
(street,city,state,zip code)
Installer's Email
W
Z
Point #1 #2 #3 #4 #5 #6 #7 #8
Distance from corner"A"
V
Distance from corner`B"
Distance from corner"C" (/
Distance from corner"D"
Ire
Town of South Windsor - Health Department
1540 Sullivan Avenue, South Windsor, CT 06074
Phone: 860-644-2511 ext.250 Fax: 860-644-7280
SEPTIC SYSTEM AS-BUILT PLAN
Date 7 d D Permit Number
Street Address 50 F S14f: ST
New Septic System Repair of Septic System Alteration of System
Number of Bedrooms OR Design Flow of Building
Type of System J l
Installed �� ~ nG rr'4- 4,` t-e ti ,5
(e.g.stone trenches,Kirdtrators,galleries etc.)
Square Footage of System: Total Length &Zv� , Width /
Effective Leaching
Area _7 oo +
Capacity of Tank i'0 0 Tank: New Existing
Length of House Sewer Pipe C�
Minimum Distance Between Septic Tank &Foundation
Minimum Distance Between Leaching Field&Foundation
Minimum Distance Between Sewage System&Nearest Well
Public Water Supply
Minimum Distance Between Leaching System and Property Boundary
Curtain Drain Required?
Minimum Distance From Leaching System to drains
(curtain,foundation,storm water,etc.)
***DRAFT DRAWING ON REVERSE SIDE OF FORM
f
SEPTIC SYSTEM AS-BUILT PLAN (Continued)
Address % FO 34 Date 7 OC,1 I S
Location of System C.S+U► t,i i side of house
(N.S.E.W.,Front,Back)
Draft a substantially correct drawing showing separation distances of septic system insallation.
Include all of the following information to provide an accurate record of the entire system
location:
At least two sides of the building nearest the system,septic tank,house sewer,
distribution boxes,trench ends,dry wells,curtain drain,potable water supply wells,and any
other features affecting the system and its location.
Installer's Na License#
Installer's Address mey i. V & 't✓Ae)dsdT— C,601?
(street,city,state,zip de)
Installer's Email r t _7�ry -.
Point #1 #2 #3 #4 #5 #6 #7 #8
Distance from corner"A"
Distance from corner"B"
Distance from corner"C"
Distance from corner"W'
Town of South Windsor — Health Department
1540 Sullivan Avenue, South Windsor, CT 06074
w Phone: 860-644-2511 ext. 250 Fax: 860-644-7280
SEPTIC SYSTEM AS-BUILT PLAN
Date Permit Number
Street Address
New Septic System Repair of Septic System Alteration of System
Number of Bedrooms OR Design Flow of Building
Type of System
Installed
(e.g.stone trenches,lnfdtrators,galleries etc.)
Square Footage of System: Total Length 2� Width
Effective Leaching
Area
Capacity of Tank 10010 U Tank: New Existing
Length of House Sewer Pipe
Minimum Distance Between Septic Tank &Foundation
Minimum Distance Between Leaching Field &Foundation
Minimum Distance Between Sewage System& Nearest Well
Public Water Supply
Minimum Distance Between Leaching System and Property Boundary
Curtain Drain Required?
Minimum Distance From Leaching System to drains
(curtain,foundation,storm water,etc.)
***DRAFT DRAWING ON REVERSE SIDE OF FORM
SEPTIC SYSTEM AS-BUILT PLAN (continued)
Address 90 FO5 Lt— S_� Date �OGZ �9,
Location of System i n side of house
(N.S.E.W.,Front,Back)
Draft a substantially correct drawing showing separation distances of septic system instillation.
Include all of the following information to provide an accurate record of the entire system
location:
At least two sides of the building nearest the system,septic tank,house sewer,
distribution boxes,trench ends,dry wells,curtain drain,potable water supply wells,and any
other features
rr affecting the system and its location.
Installer's Name V� .O�rL L,C� License#
Installer's Address 13 so 1'JAVI n 5 v �� W�n JS
(street,city,sta zip code)
Installer's Email j U4, C6�+N
� j e 'n
d P
/ Y
\3
J
'C_J
Point #1 #2 #3 #4 #5 #6 #7 #8
Distance from corner"N'
Distance from corner"W' f y
Distance from comer"C"
Distance from corner"D"
FORM#3 (Cont'd) Technical Standards for Subsurface Sewage Disposal Systems 1/l/11
Final Inspection Report
House Sewer Information
Pipe Type and ASTM Specification: Pipe Size: in.
Pipe Invert Elevations at: Pipe Length: ft.
Foundation Wall: Pitch Required:
Septic Tank: Pitch Provided:
Tank Information
Septic Tank Size: Gallons Tank Inlet Elevation:
Tank Manufacturer: Tank Outlet Elevation:
Date Manufactured: Riser Needed(Y/1):
Outlet Filter Type/Manufacturer:
Pump Ch ber
Size: Gallons Pump Alarm Checked(Y/N):
Pump Cham r
Manufacturer: Float Control Elvation Verified(Y/N):
Grease Intercep r Grease Intercepto Tank
Tank Size: Gallons Manufacturer:
Leaching System Information
Approved Aggregate: Free of silt dirt and debris(Y/N): Sieve Required(Y/N): 'V
Filter Fabric Present(Y/1):—�—Type: Aggregate Meets PHC Specifications(Y/N): y
Select Fill(Y/N):_ Meets PHC Specifications(Y/N):_ ./4J I A, Sieve Information on File(Y/N): A—
Leaching System Description(product,size,length,number of rows,level or serial etc.):
"
11 [ny%4 4/ l l�"1 S Y�.� SLAM OLI1,41 h4
Effective Leaching Area Required: sq.ft. Reserve Area Provided(N/A,Y/N):
Effective Leaching Area Provided: sq.ft. Center to Center Spacing: ft.
System Installed Per Approved Plan Elevations(Y/N): Elevations Field Verified(Y/N):
Elevation notes: Qh Id
Separation Distances
Separation Distances Conform with Approved Plan(Y/N):
Separation Distances Field Verified(Y/N):
Form#3 Technical Standards for Subsurface Sewage Disposal Systems 1/1/11
O
Application/Permit#:
Final Inspection Report
�..........vOyOR,GOr!
Local Health Department:
Property Owner: rr I �
Property Address: "t� Sac( S� Town: S. Lv�Vy&J U
Licensed Installer: (�y�.�� '(�,�lt W�e License#:
Approved Plan Information
Check one: New System Repair/Replacement System
Residential Building: bedrooms Large Tub: YES NO Garbage Disposal: YES NO
Non residential Building/Residential Institution: GPD
Plan Prepared by: Title:
Plan Approved by: Date:
Approval to Construct
Date Permit Issued: Permit Issued by:
Registered Sanitarian or Director of Health
Inspection Information
Licensed Installer
Type Date Present? Yes/No Comments
Field Stake Inspection(house,
well,property lines,system etc.)
Strip/Scarification
Sieve required(Yes/No)
Select Fill Placement
Other:
Final Inspection
Was 24 Hour(min)Installer Notice Given(Y/N): Date Final Inspection Requested:
Date of As-Built
Final Inspection Completed by: Approval:
Permit to Discharge Issued by: Date:
Registered Sanitarian or Director of Health
FORM#3(Cont'd) Technical Standards for Subsurface Sewage Disposal Systems 1/l/11
Final Inspection Report
House Sewer Information
Pipe Type and ASTM Specification: Pipe Size: in.
Pipe Invert Elevations at: Pipe Length: �`o� ft.
Foundation Wall: Pitch Required:
Septic Tank: Pitch Provided:
Tank Information
Septic Tank Size: ` l C )1> Gallons Tank Inlet Elevation:
Tank Manufacturer: Q/Q,L/l , 3L�VUftnk Outlet Elevation:
Date Manufactured: I-LO 1$ Riser Needed(Y/N):
Outlet Filter Type/Manufacturer:
Pump Chamber
Size: Gallons Pump Alarm Checked Y/1�:
Pump Chamber
Manufacturer: Float Control levation Verified(Y/N):
Grease Interceptor Grease Intercep or Tank
Tank Size: Gallons Manufacturer:
Leaching System Information
Approved Aggregate: Free of silt dirt and debris(Y/N): Sieve Required(Y/N):
Filter Fabric Present(Y/N): Type: Aggregate Meets PHC Specifications(Y/N):
Select Fill(Y/l): Meets PHC Specifications(Y/1): Sieve Information on File(YIN):
Leaching System Description(product,size,length,number of rows,level or serial etc.):
Soy, CA -1-� /A,
Effective Leaching Area Required: sq.ft. Reserve Area Provided(N/A,Y/N):
Effective Leaching Area Provided: sq.ft. Center to Center Spacing: ft.
System Installed Per Approved Plan Elevations(Y/N): Elevations Field Verified(Y/N):
Elevation notes: �-D V\ \c- �u" I-UIG a ��kAk- lets a \
aA 6i x )VAI �r-: b (ova 5,� 'N,►-2
Separation Distances
Separation Distances Conform with Approved Plan(Y/N):
Separation Distances Field Verified(Y/N):
Form#3 Technical Standards for Subsurface Sewage Disposal Systems 1/1/11
O
Application/Permit#:
Final Inspection Report
b80R•COt'..
Local Health Department:
Property Owner:
Property Address: U 5 SIr Town:
Licensed Installer: J� � \\\N W Q. License#:
Approved Plan Information
Check one: New System Repair/Replacement System
Residential Building: bedrooms Large Tub: YES NO Garbage Disposal: YES NO
Non residential Building/Residential Institution: GPD
Plan Prepared by: Title:
Plan Approved by: Date:
Approval to Construct
Date Permit Issued: Permit Issued by:
Registered Sanitarian or Director of Health
Inspection Information
Licensed Installer
Type Date Present? Yes/No Comments
Field Stake Inspection(house,
well,property lines,system etc.)
Strip/Scarification
Sieve required(Yes/No)
Select Fill Placement
Other:
Final Inspection
Was 24 Hour(min)Installer Notice Given(Y/N): Date Final Inspection Requested:
Date of As-Built
Final Infection Completed by: Approval:
Permit to Discharge Issued by: Date:
Registered Sanitarian or Director of Health
x Town of South Windsor — Health Department
- r
1540 Sullivan Avenue, South Windsor, CT 06074
Phone: 860-644-2511 ext. 248 Fax: 860-644-7280
Subsurface Sewage Disposal System Final Inspection Report
Property Owner: �(�S�-e✓ Appl/Permit#
Property Address: o Town: W(V\8 SO V'
Licensed Installer: , l �wL License#:
Approved Plan Information
Check one: New System Repair/Replacement System
Residential Building: bedrooms Large Tub: YES NO Garbage Disposal: YES NO
Nonresidential Building/Residential Institution: Wi" GPD
Plan Prepared by: )'IV/A VI)UV t? Title: ' - Gy' J-t r
Plan Approved by: IV l Date:
Approval to Construct
Date Permit Issued: Permit Issued by:
Registered Sanitarian or Director of Health
Inspection Information
Licensed Installer
Type Date Present? Yes/No Comments
Field Stake Inspection(house,
well,property lines,system etc.)
Strip/Scarification
Sieve required(Yes/No)
Select Fill Placement
Other:
Final Inspection ,S ' QJ� +' t 0-ti U
Was 24 Hour(min)Installer Notice Given(Y/N) : Date Final Inspection Requested: 1 ` Lk �1
Date of As-Built
Final Inspection Completed by: Approval:
Permit to Discharge Issued by: Date:
(Registered Sanitarian or Director of Health)
Subsurface Sewage Disposal System Final Inspection Report
House Sewer Information
Pipe Type and ASTM Specification: SO,- H U Pipe Size: in.
Pipe Invert Elevations at: Pipe Length: ft.
Foundation Wall: �j .2 2 Pitch Required: Z
Septic Tank: Pitch Provided: Z
Tank Information
Septic Tank Size : 14-y fj Gallons Tank Inlet Elevation: •�2
Tank Manufacturer: cl%(�1> eO-V C_ SySs' rif �STank Outlet Elevation:
Date Manufactured: Riser Needed(Y/N): �f
Outlet Filter Type/Manufacturer:
Pump Chamber
Size: Gallons Pump Alarm Chec d(Y/N):
Pump Chamber
Manufacturer: Float Control Elevati Verified(Y/N):
Grease Interceptor Grease Interceptor Ta
Tank Size: Gallons Manufacturer:
Leaching System Information
Approved A regate: Free of silt dirt and debris(Y/N): Sieve equired(Y/N):
Filter Fabric P sent(Y/N): Type: Aggregate Meets PH Specifications(Y/N):
Select Fill(Y/N): Meets PHC Specifications(Y/N): Sieve Info ation on File(Y/N):
Leaching System Description(product,size,length,number of rows,level or serial etc):
2 y `/ O\ (�
Effective Leaching Area Required: sq. ft. Reserve Area Provided(N/A,Y/N):
Effective Leaching Area Provided: sq. ft. Center to Center Spacing: ft.
System Installed Per Approved Plan Elevations(Y/N): Elevations Field Verified(Y/N):
Elevation notes:
Separation Distances
Separation Distances Conform with Approved Plan(Y/N):
Separation Distances Field Verified(Y/N):
0
Town of South Windsor - Health Department
1540 Sullivan Ave., South Windsor, CT 06074—Mailing Address
y 1530 Sullivan Ave. South Windsor CT 06074—Office Address
"-` � Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM
� Application/Permit#:
To the Director of Health,Town of:�i�'►'1 U�)h J443:r— Date: / 7&,
Application is hereby made f�an �proval to construct a subsurface sewage disposal system for a:
C o GC` t
r
(� - (Residential Building,Re aurant,Retail Building,etc.)
located at: 7 b F,9 'L.r' N_
x (Street Address,Lot Number,Subdivision Name,Map,Block,Lot,etc.)
New System Addition Repair Other
Owner ' 1_ S+e- Address FbS�r bid Tel.No.
Installer Van'i�lMqp A��Address f 3 30 1'hte i(1 JT' Tel.No. ao 4fice)f�5_
Installer License No. 2 71
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 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:
FEE PAID: CHECK# DATE PAID:
ray A;
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RECEIVED
SEP 17 2011
SOUTH WINDSOR
�1a HEALTH DEPT.
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-' RECEIVED
SEP 17 2018
��— SOUTH WINDSOR
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HEALTH DEPT.
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