HomeMy WebLinkAbout1993-5-5 - 1060 Ellington 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 Soutt. in sor.��%-�
Fee Paid ,J 334' lL' Date Permit Number
As a subsurface sewage disposal system installer licensed in the State of Connecticut, I
Name, Address, Telephone Number, License Number
hereby apply for a permit to construct/repair a subsurface sewage disposal system located at
and owned by
Street, Address, Lot Number Name
Address
Information to be supplied by Applicant:
Type of dwelling M11 =�
Residential, Commercial, Etc.
Number of bedrooms 3
Number of fixtures above basement
Number of fixtures in basement, if any
Type of water supply
Public -Private
If non-residential, estimated daily flow
Size of lot
. If private, type of well
Information to be supplied by Health Department:
Soil type at various levels
Percolation rate Square feet of effective leaching area required
S' f t' t nL, i d by T e of s stem
ize o sep is a yp y
Number of dry wells, trenches, etc.
units. Distance from well on same property
Curtain drain required
Yes, No
Height of system above ground water
ledge , impervious soil layer
If automatic closing is required, description
Tubs, Sinks, Toilets, Etc.
Pumped or gravity flow,
Trenches, Drywells, Etc
Distance between individual leaching
on adjoining property
maximum groLTI id wr}ler
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.
Permit Received by
;rg ature ❑ Applicant & L :ensr. Number
For Office Use Only
Permit issued by
System installed by
Final Inspection Approval
S- y —93
Date,
Date
Date _ 3
FORM #1 SOUTH WINDSOR HEALTH DEPARTMENT
APPLICATION FOR PERMIT TO CONSTRUCT OR REPAIR A SEWAGE DISPOSAL SYSTEM
(Office ;Ise Only)
APPLICATION N0.
TO THE DIREOTOR OF HEALTH
TOWN CP DATE
Application is hereby made for permit to construct a sewage disposal system for a
-7 n
.7 � 1 r"r r - -
Res ence, Store, Restaurant zt,4.
Located at /11 6 C •`
sso
rs
Name; Maps
' L' Nor.
New System Addition Repair ��f/jqct_ Other
Owner /�n,� d , Address Tel.No.
Install er�d.'`t `. ,0 - - - Address / Tel. No.
Installer License No. LO��
In accordance with detailed information stated below
Application fee paid
Signed ,• V•� - - -
duly authorized representative
GENERAL MORMATION
Subdivision Approved. Date Lot size Sq. rt.
On Public Water Supply Watershed PL., blIL ,1n D C i On Designated Wetland
SCS Soil Classification Public Sewer Scheduled
Date
If residential, number of bedrooms T�,►^eE Flood zone
If non-residential, design criteria;
Basement Fixtures
Special Equipment
(Sanitary Facilities, No. of Employees, Meals Served, Etc.)
Foundation Drains
ENGINEER'S PLAN REQUIRED
TEST DURING WET SEASON
Water Supply
Well Location Approved Yield
Type Well
Satisfactory Sample
Da
Well Driller's Name Address
rWATER SUPPLY APPROVED -
r