HomeMy WebLinkAbout1997-3-21 - 114/116 Buckland Road - Septic ApplicationTOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install a new/repair subsurface sewage disposal system. To the Health Department,
Town of South Windsor.
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Fee Paid
Date _
Permit Number
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a subsurface sewage disposal system installer licensed in the State
of Connecticut, I
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Name,
Address,
Telephone Number,
License Number
hereby apply for a
permit to construct/repair
a subsurface sewage disposal
system located at
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and owned by
Street, Address, Lot Number
Name
Address
Information to be supp4ed by Applicant:
Type of dwelling U s ( U&Inn
Residential, Commercial, Etc.
Number of bedrooms
Number of fixtures above basement
If non-residential, estimated daily flow
Size of lot
Number of fixtures in basement, if any _
Type of water supply PRI VWW . If private, type of well
Public -Private
Tubs. Sinks. Toilets. Etc.
Pumped or gravity flow,
Information to be supplied by Health Department:
Soil type at various levels _
Percolation rate —0 Square feet of effective leachi g area required
Size of septic tank Type of system 7�:"
)'00 0 f _ /� �/� Trenches, Drywells, Etc
-
Number of drys wells, trenches, etc. _ 1 Distance between individual leaching
units. Distance from well on Same property on adjoining property
Curtain drain required NV
Yes, No
Height of system above ground water
ledge impervious soil layer _
If automatic closing is required, description
maximum ground water
I
A PLOT PLAN INDICATING LOCATION OF PROPOSED STRUCTURE, WATER SUPPLY, SEPTIC SYSTEM, EM-
BANKMENTS, WATERCOURSES, PROPERTY LINES AND ALSO INDICATING EXISTING AND PROPOSED
FINISHED GRADES MUST BE SUBMITTED BEFORE THIS PERMIT CAN BE ISSUED.
THIS PERMIT IS NOT TRANSFERRABLE FROM PERSON TO PERSON OR FROM PLACE TO PLACE.
NO PART OF THE SYSTEM SHALL BE BACKFILLED UNTIL IT HAS BEEN INSPECTED AND APPROVED BY THE
SANITARIAN.
SPECIFICATION AND REQUIREMENTS AS STATED IN THIS PERMIT MUST BE MET AND ANY CHANGES MUST
BE APPROVED BY THE TOWN SANITARIAN BEFORE FINAL APPROVAL WILL BE GIVEN.
THIS PERMIT SHALL NOT BE CONSTRUED AS PERMISSION TO CREATE A NUISANCE CONDITION NOR IS
THIS SYSTEM GUARANTEED BY THE HEALTH DEPARTMENT.
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Permit Received by � 't �� �� 1 `� Date
Signature of Applicant & License NurTlibet
For Office Use Only
Permit issued by
System installed by
Final Inspection Approval
Date
Date
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SOUTH WINDSOR HEALTH DEPARTMENT
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