HomeMy WebLinkAboutSeptic 98Newberry Road Newberry Road a
Town of South Windsor — Health Department
q o 1540 Sullivan Avenue, South Windsor, CT 06074
x Phone: 860-644-2511 ext. 250 Fax: 860-644-7280
,ties°R C°�r B100a APPLICATION
(for building conversion,change of use,building addition,accessory structure and lot line change)
Standard application review time is 5--11. (
0 days,if soil testing is needed,
additional time will be required to F
complete the review process.
S
Street Address of Propose Activity/Structure
Owner Name Mailing Address Telephone
Applicant Name(if different than owner) Mailing Address Telephone
Describe the proposed structure or activity with dimensions:
RECEIVED
Residential DEC Q 12015
_,'' Number of existing bedrooms
SOUTH WINDSOR
Non-residential Please describe HEALTH DEPT.
Property served by on-site well? Y O If No,List name of water company
Property served by septic system? N Age of system, ���rS Date last pumped RC I`-{
Plot plan—attach a scaled drawing showing property lines and dimensions,location and size of existing and proposed
structures,and site features such as driveways,wells and septic systems, drains and water courses.
Building plan—attach a sketch/floor plan of the proposed structure, addition or renovation showing existing and
proposed rooms with door and window locations.
Soil test data(deep test pits and percolation test) are required for the review of this application.
if the data is NOT available,you will need to schedule an appointment with the health department for soil testing.
As property owner or duly authorized representative of the property owner of the above referenced property,I agree to allow the
health department staff to enter the above referenced property as part of this B 100a application review process.I further agree that
this authorization to enter the subject property may extend through a period of time ending with the final B 100a application
approval and affirm such with my signature below.
Applicant Signature: Qt Date: J'�
FOR OFFICE
`�USE ONLY: ` �A, �,, 4
Approved: U N By:� }"� t 1 S _._Date:,
Comments/Conditions:
May 2011
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WELL COMPLETION REPORT STATE OF CONNECTIf17r
cPR-9RFv.tt-ss DEPARTMENT OF CONSUMER PROTECTION
Do NOT fill in'
WELL DRILLING RGARD STATE WELL NO.
165 CAPITOL AVE.
HARTFORD,CONNECTICUT 06106 OTHER NO.
NAME fir :
OWNER JIME.7F SUTTON r. Y 3L ti. 1AsUL M.V HI.SJDI tLtiu+W'1TS OTe
No. & Street I ���� (Lot Number)
Of WELL LOCATION I Li is 0A,D ) r�'YOU T.C"ao I�IRDBOR
BUSINESS
PROPOSED ® DOMESTIC El ESTABLISHMENT FARM TEST WELL
USE OF
WELL PUBLIC SUPPLY INDUSTRIAL CO If
CONDITIONING a JSpecy)
COMPRESSED CABLE
DRILLING
ROTARY AIR PERCUSSION PERCUSSION (specify)-
EQUIPMENT y)-
EQUIPMENT .
PERCUSSIONCASING LENGTH (feet) DIAMETER (inches) WEIGHT PFR FOOT wAS CASING GROUTED?
DETAflS 158 46 $J3 ® THREADED; WELDED]�F=YESOO YES NO
YIELD HOURS YIELD(G.P.M.)
TEST L7 BAILED PUMPED COMPRESSED AIR
WATER MEASURE FROM LAND SURFACE—STATIC(Specify feeQ DURING YIELD ITST(feet) Depth of Completed Well
LEVEL tit in feet below Land surface: 05
MAKE TENGTM OPEN TO AQUIFER (feet)
i
SCREEN..
i.DETAILS SLOT SIZE DIPNiETER(inches) GRAVEL SIZE(inches) FROM(feet) TO(feet
IF GRAVEL Diometer of well including
f PACii;fD: grovel pack(inches):
DEPTH FROM LAND SURFACE FORMATION DE5CRIPI)DN Sketch exact location of well with distonces, to at lens+
FEET TO FEET two permanent landmarks.
and
11 43 Sana Gr vet
Bedrock
� If yield was tested at different depths during drilling, list below
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I r
FEET GALLONS PER MINUTE
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DATE'WELL COMPLETED PERMIT
NO. �y REGISTRATION NO. DATE OF REPORT } WEL D ER(Signatuyej-- yn
. 7. £3 G.'wry C] EJ +�
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DEPT. OF EENVIORNMENTAL PROTECTION-WATER RESOURCES
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F . IRON PIN
900-05�-IT"
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900-00'-00"
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IRON PIN
N�'JWBERA
INLAND WETLANDS SOILS r
CLASSIFIED AS WALPOLE 1