HomeMy WebLinkAbout2003-4-17 - 12 Green Lane - 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 Wi dsgr.
Fee Paid -1° -� ►i 1')S) Date �/' l7 �y3 Permit Number
As a subsurface sewa a disposal _ system installer licensed in the State of Connecticut, I
Name, Address, Telephone Number,
hereby apply for a permit to construct/repair a subsurface sewage
4; R e1 ;L and owned by
Street, Address, Lot Number
Address
License Number
disposal system located at
Name
Information to be supp "ed by plicant:
Type of dwelling If non-residential, estimated daily flow
Residential, Commercial, Etc.
Number of bedrooms
Number of fixtures above basement
Number of fixtures in basement, if any
Type of water supply
Public -Private
Size of lot
If private, type of well
Tubs, Sinks, Toilets, Etc.
Pumped or gravity flow,
Information to be supplied by Health Department:
Soil type at various levels
Percolation rate Square feet of effective leaching area required
Size of septic tank Type of system
Trenches, Drywells, Etc.
Number of dry wells, trenches, etc. °�1`,� Distance between individual leaching
units. Distance from well on same property on adjoining property
Curtain drain required
Yes, No
Height of system above ground water
ledge impervious soil layer
If automatic closing is required, description
"`.ftximum 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.
A/
Permit Received by �3900
Signature nt Applicant & License Number
For Office Use Only
Permit issued by
System installed by
Final Inspection Approval
Date L'+m v Q3
Date
Date