HomeMy WebLinkAboutSeptic Repair 429 Griffin Road •
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::. TQyn of South Windsor'= Heath De�artm.ent
. 1540;SuUivan•Avenue, S.c�uth lA dsor,CT -fl6074
' «� Phone, 860-644-2511 eXf. 248 .Faz: 860-6447280
APPLICATION FOR A�'PROWAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPE35 L SY3TEM. '. ..:..'
.ApplicatiorsfPermit#:
To the Director ofHealth Town o
Application is hereby.ri ade:for an approval to constrict a subsurface.sewage disposal system€6r a:'
004
(R ding,Restaurant,Retail.Bulding,etc.)
esidential'al-Building-
looatgd ar4 . � V'r :.y
(5treefiAddress,Lot Number;Subdivision:Name�:Map,Block,Lot,etc.)
New System Addition' Repair
Owner:/ GC T t f �C:':14' /',OM ass
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Installer /�/d•�9 4 n Address s' ✓
1
)unStal ei:licertse
In accordance with detailed information stated below:..
Application'fee paid. Signed
Owner or dul i�uthbrized re resentative.
---------------- - ----- - -- -- =-- = ---- - -
GE>vERAI�lli+ of ATIOly
Soil Tests Conducted(Date) : sq,$
Lot size
Area of Spacial Concert(YIN); Tf es Reasons : < h -
y t:) ce / :Grp
Basis of Desi ri #of Bedroottls Restaurant Seats Buildin Size,etc. : . U�` �g ( g- )
Engineered Plan.Required&o. :)Eyes,Name of Eiigirieer.
Address of Engineer:
Design Plan A. roved'.Y
lip ( ;��. . owed l'laa:: Revision Date;
.,.,`Date o€Appr
Type of Water Supply If well;has:iocafioii been approved
Well Driller Name Address
OPFIGE USE OiVLY
Approval 10. onstruct issued liy: Date:
(Director of Health or Registered Sanitarian)
Signature: Title:
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