HomeMy WebLinkAbout1979-10-25 - 125 Edwin Road - Septic ApplicationTOWN OF SOUTH WINDSOR
HEALTH DEPARTMENT
Application for permit to install ne /repair subsurface sewage disposal system. To the Health Department,
Town of South Windsor. L
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Fee Paid ,Qldc Pe A.� r Date C Permit Number Tay
As 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
1'Z5- C!J'k ),A, Sr✓ (,C) So and owned by ::'4, .� /I lvd-oL- Chnahon-nh-.ii
Sir t, Address, Lot Number Name
Address
Information to be supplied by Applicant:
Type of dwelling --- If non-residential, estimated daily flow
Residential, Commercial, Etc.
Number of bedrooms Size of lot
Number of fixtures above basement
Number of fixtures in basement, if any
Type of water supply _ /7v�/%ram . if private, type of well
PUDIIC-Private
Information to be supplied by Health Department:
Tubs, Sinks, Toilets, Etc.
Pumped orgravity flow,
Soil type at various levels 4J117,
Percolation rate M+Fr LErf-1 Square feet of effective leaching area required
Size of septic tank occ, Type of system
Trenches D-wells Etc
Number of dry wells, trenches, etc.
units. Distance from well on same property
Curtain drain required n U
Yes, No
Height of system above ground water
ledge impervious soil layer
If automatic closing is required, description
Distance between individual leaching
on adjoining property
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 GUARANTEE BY THE HEALTH DEPARTMENT.
Permit Received Date
Sig Sure of ApplickJZLicense Number
For Office Use Only
Permit issued by fir' Date — �a -zs =� 9
System installed by dr CI•arrr a rig-�e.�
Final Inspection Approval Date
IUWN Ur- JUUl'H W1NUbUK
APPLICATION FOR SITE INVESTIGATION AND PERCOLATION TEST
Information to be su2plied by A licant:
Name and Address of Applicant Jr
Location of Property
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Address, Street, Lot Number
Name and Address of Owner
Site of Lot Type of Water Supply_
Signature of Applica t _ Date 7 -
Information to be supplied by Health Department:
Description of Property - {OV,4.4n ek--
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Soil.Conditions:
Observation Pit #1 Observation Pit #2 Observation Pit #3
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Lost of Percolation TP.qtc-
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Test
Water
Time
Rate
Male 7
De th
Time
Level
Interval
Dry
Min./In.
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Design Rate
Remarks ns- C. w
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to
Test
Role #
De th
Time
Water
I Level
Time
Interval
Dro
Rate
Min. /In.
Design Rate
Tests conducted by Date
Approved for septic system - yes _ no OF
Signature of Sanitarian'. Date
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