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Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
'%, _ 1530 Sullivan Ave., South Windsor, CT 06074—Office Address
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Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
PERMIT TO DISCHARGE
Approval is hereby given to L(A w'4�& Q (rl in accordance with Public
(Property Owner)
Health Code Section 19-13-B 103e(h)to discharge to a subsurface sewage disposal system located at
s li- .
(Street Address)
in the town of CT that will receive domestic sewage from a:
Residential building containing bedrooms. Single family(Y/N): \
Restaurant containing seats.
Commercial/Office building providing square feet.
Other structure as described:
Design Flow= y 31D gallons per day. Permitted Flow= (.I gallons per day.
The design flow shall equal the permitted flow, except for non-compliant repairs(See Section IV D).
In order to provide a sufficient factor of safety it is recommended that the average daily discharge not
exceed 2/3 of the permitted flow or 3 p o gallons per day.
Operation and Maintenance: Septic tank shall be inspected regularly and pumped as needed but not
less frequently than every five years. The septic tank has an effluent filter(Y/N)_�---. Effluent filters
require periodic cleaning. Failure to clean filters can result in sewage backup into the building or effluent
breakout. Restaurants serviced by external grease interceptor tank(s) require quarterly inspections and
cleaning as necessary. Tank pump-outs tracked by local health department(Y/N)_A/ If yes,
stipulate pump-out requirements:
Special Requirements and Restrictions: 1. In the future if there is a septic system malfunction or
failure it must be addressed.
Exceptions(Repairs Only):
File Information: Construction Permit No. Approved as-built on�flile(Y/N) _ .
Date of Final Inspection: _1 1 3 U\\$ Inspected By: - � 1 V A-V1 S rr
Permit Issuance: Issued by: 4ElAU �A�lis �S I Q-S Title:
(Director of Health or Registered Sanitarian)
Signature: Date: ��\