HomeMy WebLinkAbout2002-7-24 - 17 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 Windsor. CUC'�.
Fee PaidU Date y Permit Number
a subsurface w e dispgsaI system, ins aller. I'ce sed in t St a0 of Connecticu
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Name,
hGeby ply for a edit
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Street�5 , , Address, Lot NumbWr
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Address
Address, Telephone Number, License Number
to construct/repair a subsurface sewage dispsosal srysteT �pci$ed at
12 and owned by a,�J Q CL C j[ JIzo
Name
Information to be supplie by Appli ant: L
Type of dwelling icie,-'> I eA�)
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 ell ` I1 ,C If private, type of well
Public -Private
Information to be supplied by Health Department:
Soil type at various levels
Tubs, Sinks, Toilets, Etc.
Pumped or gravity flow,
Percolation rate Square feet of effective leaching a a required
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
Curtain drain required
Yes, No
Height of system above ground water maximum groundwater
ledge , impervious soil layer
If automatic closing is required, description
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 byJ�J16_2�`� ` G � Date
signature of ApnWpil & License Number
For Office Use Only
Permit issued by f�il Date
System installed by S C D�' GcG r' (�C
Final Inspection Approval Date
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