HomeMy WebLinkAbout1994-5-25 - 22 Chapel 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
Fee Paid L) Date S =Z'3 —1Y Permit Number
As a subsurface sewage disposal system installer licensed in the State of Connecticut, I
Z )Z 7 Y Y
Name, Address, Talephone Number, License Number
hereby M�w
ermit to construct/repair a subsurface sewage disposal system located at
0� fi) _ and owned by
Street, Address, Lot Number Name
Address
Information to be supplied by Applicant:
Type of dwelling '
Residential, Corr mercial, Etc.
Number of bedrooms 5
Number of fixtures above basement
If non-residential, estimated daily flow
Size of lot dce"-
Tubs, Sinks, Toilets, Etc
Number of fixtures in basement, if any �.
Pumped orgravity flow,
Type of water supply % If private, type of well
Public -Private
Information to be supplied by Health Department:
Soil type at various levels -
Percolation rate Square feet of effective leaching area requiredS
Size of septic tank Type of system
Trenches, Drywells, Etc.
Number of dry wells, trenches, etc. Distance between individual leaching
units. Distance from well on same property on adjoining property 4�
Curtain drain required
Yes, No
Height of system Bove ground water / maximum groundwater
ledge impervious soil layer
If automatic losing is required, description —
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 NPISANCF D ITION NOR IS
THIS SYSTEM GUARANTEED BY THE HEALTH DEPARTMENT. k`"�
Permit Received by f -71 V 7 Date
e na re o! Applicant E iP.efte Number
For Office Use Only
Permit issued by _
System installed by
Final Inspection Approval
Date
IQ� Date J` ^2Lt —