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HomeMy WebLinkAbout2015-11-23 - 1747 John Fitch Boulevard - Septic ApplicationTown of South Windsor —Health Department 1540 Sullivan Avenue,South Windsor,CT 06074 Phone:860-644-2511 ext.250 Fax:860-644-7280 APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM Application/Permit #: TO the Director of Health,Town of:5°‘-"A'\'\w ‘’\‘)5 ()(Date:n \w t 15‘l Application is hereby made for an approval to construct a subsurface sewage disposal system for a:‘gvAcluw‘ (Residential Building,Restaurant,Retail Buildiaé,etc.) located at:17 l—l 7 30M“yllck $‘Vd (Street Address,Lot Number,Subdivision Name,Map,Block,Lot,etc.) In accordance with detailed information stated below: Basis of Design (#of Bedrooms,Restaurant Seats,Building Size,etc):3 bcdcoo m 3 SCANNED New System Addition Repair X Other Owner Address TelNo. Installer AD ‘3 5 Cg)Aqc.Address 776x («brawl lent}-;+Tel Ne $260 ~~(aw -057°} Mkn we“,or Mb nchcs lzf CT Installer License No.é i7 kl Application fee paid Signed (Owner or duly authorized representative) GENERAL INFORMATION Soil Tests Conducted (Date):la l 13 I Ls‘’Lot size'l sq.ft. Area of Special Concern (Y/N):NO If yes,Reason(s): Engineered Plan Required (Y/N):NO If yes,Name of Engineer: Address of Engineer: Design Plan Approved (Y/N):Date of Approved Plan:Revision Date: w e\\(a Ci”Type of Water Supply If well,has location been approved (Y/N)~AJIJ (AR,l ll ft:l " Well Dliller’s Name:vet-a u e it g0Address: OFFICE USE ONLY Approval to Construct issued by:Date: (Director of Health or Registered Sanitarian) Signature:Title: Town of South Windsor —Health Department 1540 Sullivan Avenue,South Windsor,CT 06074 Phone:860-644-2511 ext.248 Fax:860-644-7280 PERMIT TO DISCHARGE Approval is hereby given to US Bank in accordance with Public (Property Owner) Health Code Section l9-l3-B103e (h)to discharge to a subsurface sewage disposal system located at 1747 John Fitch Boulevard (Street Address) Other structure as described: Design Flow =450 gallons per day.Permitted Flow =450 gallons per day. The design flow shall equal the permitted flow,except for non—compliant repairs (See Section [V D). In order to provide a sufficient factor of safety it is recommended that the average daily discharge not exceed 2/3 of the permitted flow or 300 gallons per day. Operation and Maintenance:Septic tank shall be inspected regularly and pumped as needed but not less frequently than every five years.The septic tank has an effluent filter (Y/N)Yes .Effluent filters require periodic cleaning.Failure t0 clean filters can result in sewage backup into the building or effluent breakout.Restaurants serviced by external grease interceptor tank(s)require quarterly inspections and cleaning as necessary.Tank pump-outs tracked by local health department (Y/N N Ifyes,stipulate pump—out requirements:) Special Requirements and Restrictions:l.ln the future.ifthere is a septic system malfunction or failure.it must be addressed. Exceptions (Repairs Only): File Information:Construction Permit No..Approved as—built on file (YfN)Yes Date of Final Inspection:l2/8/l 5 Inspected By:Heather Oatis Heather Oatis.REHS Title:Env.Health OfficerPermitIssuance:Issued by: (Director ofl lcalth or Registered Sanitarian) Signature:1,.)M Date:17 il’lllfvv\ SCANW in the town of South Windsor ,CT that will receive domestic sewage from a: Residential building containing J bedrooms.Single family (Y/N):_Y Restaurant containing seats. Commercial/Office building providing square feet. 1!'*‘ln('Mgq MATERIALS TESTING INC. :55 LAURA STREET -NEW HAVEN,CONNECTICUT 06512 -(203)468-5216‘Iul"42 BOSTON POST ROAD -WILLIMANTIC,CONNECTICUT 06226 -(860)423-1972 .-‘‘ DATE:10—30—1 5 REPORT:M4407 CLIENT:Desiato Sand &Gravel 999 Stafford Road Storrs,CT 06268 PROJECT:Client‘slnformation SUBJECT:WASHED SIEVE ANALYSIS (ASTM C-136,D-1140) Material:Sand for Septic Source:Desiato Sand &Gravel,Storrs,CT //"rrnl\\"\ Sampled:by client and delivered to MTI on 10/29/15 Sieve Size Percent Passing Mantis Wastewater Leaching System Specification 3/3"(9.5mm)100 100 #4 (4.75mm)99 95—100 #8 (2.36mm)84 80-100 #16 (1 .18mm)65 50—85 #30 (600pm)43 25-60 #50 (300pm)2O 5-30 #100 (150um)2 0—10 #200 (75pm)0.9 0-5 / This material as sampled and delivered meets the listed specification. Materials Testing,Inc. Richard C.Kearns till; William J.Soucy RECEIVEE1cc:Client wlb DEC l 7 2015 Test reports may not be reproduced without the express permission of Materials Testing,inc.Results only relate to items tested.SOUTH WINDSORHEALTHDEPT. b6533‘n Ct:*e {*Em RECEIVED DEC 03 2015 SOUTH WINDsoRHEALTHDEPT. ‘5 Ec Roma “M S ELA No M L5 33 No 255%“,c3me, 1W£@ fmf’r 1 gfi Eo'Ham Top 09 umQr UN)? iiiqg 1 égLig / EX §raga 3"3.qg f/g Town of Sauth Windsar —-Heaith Department 1541}Sullivan Avenue,$ouih Windsor,CT 06074 Phona:sea-W25?!extzsa Fax:W72£0 SEPTIC SYSTEM AS-BUILT PLAN Date .j W S’Permit Number smm‘wm 5am Rw MA W Sawmgystm V/Rapalr of Septic 8m wAlmratim @vSysm Number of Bedrooms 3 OR Design Flow of Building Egective LeachingArea Ll 01 5’ Capacity af'l‘ank we 0 Tank:New X Curta§n Drain Requireti? Minimum Distance From Lawnmg Sm ta drains A/l A (curtain,faumlatiém,3mm water,em) “*DRABTnRAWIm ON REV£RSE SIDE OF Emai Type of SystemMW E ha’x [‘kam m .3 (cg.Shane trenches,Winters,gailem etc.) oSqéareFfaotageofSystem:Tom Length H §Width ‘“3 Ia5Length9fEuuseSewerPipe Minimum Bistmce Batman Septic Tank &Foundation,”X}5 Minimum Distanae Batween melting Field 8t Foundation lé5 wnimum Bistance Between Sewage System &Nearest Wei!Public Water Supply:35’‘ Min§mum Distance Eetween Leaching System and Proyerty Bmmdm'y i S Adams m7 mm $Mn mg Rum: $$£LW~MMLocationofSystem Draft a sabstantiaily correct drawingshawing sewatian ém‘mnees of seytia symm mailman. Inciude alt af the foliowmg information ta previde an mime recon}of the smite system 1mm At least two sides of the huilding nearest the system;We tank,heme sewer, wwwrbm mach ends,dry wells,mm£imim gawk wamr sappiywmk,nné any other feamm affatiag the system and its lecatiom EME.a?”siae of house Inswkr’s Nam lustaller’s Agim ??m maimmwwde) Instalkr’sEmwl 14.3%Mng§wc¥m~¢km QM [nunx“ Limit QWLg M m 5M5 QX Ju5¥§n Ecwlép waaQiM¢3 5%, a !)5¢c¢it& EPTIC SYSTEM AS-BUILT PLAN zemm) Date i L§ S Point #1 #2 "#3 #4 #5 #6 #7 #8mmcamer“A”LN was 2%M {2%.‘1 Mammeomer “3”5H:gé‘E 0761.;mg:qga mm aural-“(P Minoan-meow “v” Town of South Windsor —Health Department 1540 Sullivan Avenue,South Windsor,CT 06074 Phone:860-644-2511 ext.243 Fax:860-644—7280 Subsurface Sewage Disposal System Final Inspection Report Property Owner:Appl/Pennit # Property A ddress:l /\ %I\\BOMW Q XVKKA {g U E Town:S l l/U \V\kgu ‘/ Licensed Installer:License #: Approved Plan Information Check one:New System Repair/Replacement System \/ ResidentialBuilding:1 bedrooms Large Tub:YES @ Garbage Disposal:YES @\J Non residential Building/Residential Institution:GPD Plan Prepared by:Title: Plan Approved by:Date: Approval to Construct Date Permit Issued:l 7\q \l r Permit Issued by:A ,0 a 5(\&Q S Registered Sanitarian or Director of Health Inspection Information Was 24 Hour (min)Installer Notice Given (Y/N):Date Final Inspection Requested:\1\W \i r Date of As-Built Final Inspection Completed by:\xx -C [A 3N 5 Approval: Permit to Discharge Issued by:Date: (Registered Sanitarian or Director of Health) Type Date Licensed Installer Present?Yes/No Comments Field Stake Inspection (house, well,property lines,system etc.) Strip/Scarification \1 \3 \\r I VKJM Select Fill Placement Sieve required (Yes/No) Other: Final Inspection Subsurface Sewage Disposal System Final Inspection Report House Sewer Information Pipe Type and ASTM Specification:3 (\,\,k‘\0 Pipe Size:L in. Pipe Invert Elevations at:Pipe Length:ft. Foundation Wall:ii ST W v Pitch Required:L\k Sf i Y\(’\vU) Septic Tank:Kai lo PitchProvided:Lli O Y i mum \ Tank Information Pump Chamber Manufacturer:Float Control Elevation rifled (Y/N):vGreaseInterceptor\Grease Interceptor Tank Tank Size:Gallons Manufacturer: Leaching System Information xApprovedAggregate:Free of silt dirt and debris (Y/N):Sieve Required (Y/N):\Filter Fabric Present (Y/N):Type:Aggregate Meets PHC Specifications (Y/N): Select Fill (Y/N):Meets PHC Specifications (Y/N):Sieve Information on File (Y/N): Leaching System Description (product,size,length,number of rows,level or serial etc):Z o l Z 3y ' Sap (in L)cw M \(VVM \(\5o Effective Leaching Area Required:O 3”sq.ft.Reserve Area Provided (N/A,Y/N):A]i A Effective Leaching Area Provided:k .Y sq.ft.Center to Center Spacing:/t 2 t Ax ft. System Installed Per Approved Plan Elevations (Y/N):\Elevations Field Verified (Y/N):\f Elevation notes \y g)5 W)D be \n . A)OU B box ()Lx iv \(Separation Distances Conform with Approved Plan (Y/N): Separation Distances Field Verified (Y/N):I x Septic Tank Size :(O O O Gallons Tank Inlet Elevation:LO i l O Tank Manufacturer::>o \\@kj Tank Outlet Elevation:b .g 5/ Date Manufactured‘l ‘Z,g \\\Riser Needed (Y/N): Outlet Filter Type/Manufacturer Qt)\A,l L)C k.Pump Chamber Size.Gallons Pump Alarm Checked(Y/N): {\xw“Lgc’yc/L’W&F\mW C NM “m ,mé wmu M DH? :igWUx OWVULAA MM“:’i/V \Wn Wf \fgt’t;\Cw/ii\(l"\t hLxV @tw w‘> cmnwd w to nmw tutu wttwwSeparationDistances Town of South Windsor -Health Department 1540 Sullivan Avenue,South Windsor,CT 06074-2786 Phone:860-644-2511 ext.248 Fax:860-644-7280 APPROVAL TO CONSTRUCT OR REPAIR SEWAGE DISPOSAL SYSTEM Approval is hereby granted for the construction/repair of a subsurface sewage disposal system at the property described below: PROPERTY OWNER(S):US Bank STREET ADDRESS:1747 John Fitch Boulevard TOWN:South Windsor INSTALLER:Justin Breult CT.LIC #EXPIRES:9/30/16 RESIDENTIAL:#of Bedrooms -3 INSTRUCTIONS FOR INSTALLER 1.Construction plot plan submitted and approved by this office must be adhered to. 2.This office must be contacted for approval if any change is going to be made in the system location,size or'design,or any changes in house,well or property line locations. 3.Any NEWsewage disposal system must conform to ALL requirements of Section 19-13-B103 of the CT Public Health Code. 4.ALL new construction to be under DIRECT supervision of a CT licensed installer under Section 20-341 of the CT General Statutes. 5.The installer is RESPONSIBLE for VERIFYING LOCA TIONS of PROPERTYLINES,WELLS, and BURIED UTILITYLINES prior to construction. 6.Installer to notify South Windsor Health Dept.24 hours prior to the start of construction. 7.Installer to have septic tank covers removed at the time of inspection. SPECIFIC INSTRUCTIONS: Install per approved plan,(Justin Breault,Dated:12/3/15). Licensed Installer to field stake house,well (if applicable),permanent benchmark,and septic system.Offset stakes to include bottom of trench or flow line elevations.Health Dept,staff to conduct stake inspection prior to construction of system. Permanent benchmark to be set within 5O feet horizontally and 12 feet vertically of septic system. Install a 1,000 gallon two-compartment septic tank,with an approved outlet hlter.Risers are to be installed if there is to be more than 12"cover over septic tank cleanouts. 5.Install 495 square feet of effective leaching area,consisting of one row 45 feet long of Mantis 536-8 units,bedded on the bottom and sides with sand fill meeting both the manufacturer’s and select till specihcations.System to be installed per manufacturer’s specihcations.Systems with total cover that exceeds eighteen (18)inches as measured from the top of the units to finished grade shall be vented at the distal (far)end of the system. Current Sieve analysis (within 3O days)for sand fill must be submitted to the South Windsor Health Department. Max depth into original grade is not to exceed one hundred (1 00)inches. Installer to schedule,and be present for final inspection with Health Dept.staff.Level to be set up for verification of elevations OR an engineer's/surveyors as built will be required 9 Installer to complete and submit septlc system as bUIlt plan and drawmg With ties to the house 10 EXIstIng septic system to be properly abandoned 6e. SIGNATURE:OW DATEISSUED:12/7/15 RENEWRE? APPROVED BY:Heather Oatis,REHS,HHS EXPIRES:12/7/15 EXPIRES:// Nx- #w THIS PERMIT IS VALID FOR A PERIOD OF ONE YEAR FROM DATE OF ISSUE.IN ACCORDANCE WITH THE CT PUBLIC HEALTH CODE SECTION 19-13-BI03e(F)(I).ONE RENEWAL IS POSSIBLE PROVIDED SOUTH WINDSOR HEALTH DEPARTMENT IS NOTIFIED PRIOR TO THE EXPIRATION DATE NOTED ABOVE.IF PERMIT EXPIRES,INSTALLERS ARE CHANGED,OR ANY OTHER DEVIATION FROM THE ORIGINAL PERMIT,A NEW APPLICATION MUST BE COMPLETED AND ALL APPLICABLE FEES MUST BE PAID. FEE PAID:10.00 Due (Check for wrong amount submitted with plan)CHECK N/A DATE PAID: Vision Government SOlutions Page 1 of 3 1747 JOHN FITCH BLVD Location 1747 JOHN FITCH BLVD Assessment $177,200 Mblu 121/55///Appraisal $253,000 Acct#47701747 PID 2394 Owner US BANK Building Count 1 Current Value I Appraisal Valuation Year Improvements La nd Total $135,500 $117,500 Ei $253,000 l Assessment i Land 5 ( Valuation Year Improvements Total Style ,Colonial hftnJ/(Iie voqi (‘nm/QnnfhW1nrlQnr(‘T/pgrnpl nenv9piri=7104 1 7/7/701 g $94,900 3 $82,300J $177,200 Owner of Record Owner US BANK Sale Price $0 Co-Owner C/O WELLS FARGO BANK Certificate Address 3476 STATEVIEW BLVD Book &Page 2420/337 FORT MILL,SC 29715 Sale Date 08/12/2014 Instrument 14 Ownership History h'History Owner Sale Price Certlflcate Book &Page Instrument Sale Date US BANK $2420/337 T 14 08/12/2014 E PAPADOGIANNIS PEI’ER &MARY $170,00 1645/151 00 08/31/2004 DILOREIO MARIO &ROSE $116,000 :i 448/91 00 06/30/1986 Building Information Building 1 :Section 1 Year Built:1941 Living Area:2570 Building Photo Replacement Cost:$233,634 Building Percent 58 Good: Replacement Cost Less Depreciation:$135,500 H Building Attributes .1 Field Description Vision Governmant Solution Page 2 of 3 Model :Residential Grade:B- Stories 2.4 Occupancy 1 Exterior Wall 1 Aluminum Sidng K Exterior Wall 2 Roof Structu re §Gable Roof Cover Asphalt Interior Wall 1 Plaster i Interior Wall 2 (http://images.vgsi.com/photos/SouthWindsorCTPhotos//\00 \OD\17/87.JPG)‘interior Flr 1 Hardwood Interior Fir 2 li Building Layout iHeatFuel:Oil Heat Type:Hot Water AC Percent ;0 Total Bedrooms:i 3 Bedrooms §Full Bthrms:51 Half Baths::1 tra Fixtures E 1x ETotal Rooms:>7 Bath Style:Averagei li Kitchen Style:Average :Num Kitchens .1 ‘Fireplace(s)2 Extra Opening(s)0 l 9 Gas Fireplace(s)O %Attic Fin 0 0 Poured Conc 0 100 SF FBM 0 Fin Bsmt Quai Bsmt Access None Extra Features 1ExtraFeaturesLegend l No Data for Extra Features Land Land Use Land Line Valuation hffn'//niq vnqi r‘nm/Qnnfln‘U§nr1enrr‘T/pnrr‘pl nenv9pirl:’)’2QA 1 7/7/7n1 < s i Building Sub-Areas Ligm i BAS 1 Code First Floor Description Gross Living Area Area l y 1238 ‘1238 FUS Finished Upper Story Finished Half Story 900 ‘900 864 l 432liFHSi— BasementBSM 864 994 ii 0i ig ODCKDeck FGR Garage 572 E O FOP ‘Open Porch 28 l o E 5460 2570 Vision Government Solutions Use Code 101 Description Res Dwelling Zone A40 Neighborhood Alt Land Appr No Category Size (Acres)0.7 Frontage O Depth 0 Assessed Value $82,300 Appraised Value $117,500 Page 3 of 3 hffn‘NoiQ voei nnm/§mifhWinriqnr(‘T/Pnrnel ncnv‘7piri:’)’204 19/7/9015 Ix ii Outbuildings Valuation History i iOutbuildingsL_e9_end No Data for Outbuildings Appraisal Valuation Year Improvements Land $135,500 i $117,500 Total $253,000 l2014 2014 $135,500 $117,500 $253,000 l 2013 $135,500 l Assessment Valuation Year Improvements $117,500 $253,000 Land Total 2014 $94,900 $82,300 $177,200 i 2014 $94,900 $82,300 $177,200 * 2013 $94,900}$82,300 $177,200 (c)2014 Vision Govemment Solutions,lnc.All rights reserved. 1 htfhQ'H‘xnx/vv Mimi-nee of Unv/T .nnlznn/printT inpnephptaiic aqnv9prpri=1 (\71 Q70Rrnnn+an+=1 ’1 19/7/’){\1< Page 1 ofPrintLookupDetails State of Connecticut Looku Detail View Name Name JusnN M BREAULT License Information Hookup License Type License Number Expiration Date Granted Date License Name License Status Licensure Actions or Pending Charges Sub-Surface SewageInstaller 6174 09/30/2016 06/26/2012 JUSTIN M BREAULT ACTIVE None Generated on:12/7/2015 2:55:41 PM cxw;'27;”Mm %4?&$7363 w.\_4‘ag>§€;z§‘250 QéWW 0w4¥ $‘aig Céxvvnw WW3 30 WWW:v13 §bk = Non-Engineered Plan Review Checklist Local Variances can be granted for ail parts of the code except well separation distances and septic systems on Iots separate from the building served (show variances on permit and P to D and fax P to D to state).These two variances must be granted by the State DPH Environmental Engineering Program-860-509-7296. Reviewed by Dat Towe n Rev 6/07 Address:B Plan submitted and signed with numberEFeeforserviceformcompletedand filedEEntertheaddressintotheFileboundand updateBCheckneighboringhousefilesandsoilsdata, Conduct a site Visit wrth the proposed plan andBPropertylines/benchmark per plan BM Benchmark locationBNorthArrowand/or road reference o Walk property and adjacent propertyBLedgeoutcropsand/or bouldersDWatercourse,water bodies,D Contours/ground shots shownDCheckwellsandprovidewellBLocateanyunusualitemslikeDLeachingrowstobesetlevelinoriginalsoil or surrounded by stone,which can receive 1’credit Designer:Contact #: bedrooms/design flow Date: Date: Master Sheet w/date received/type review. property lines,septic systems,wells and drains check if correct near septic property lines staked by LS If needed Elevation prowded and accurate to identify the following match the plan: flagged wetlands and standing water after heavy rainfall match the planabandonment for dug wells if needed existing curtain drains or drainage pipesselectfill.Leaching galleries and infiltrators are on each end when determining ELA. Plot Plan OK Location Proposed (ft)OK 7§t Floor Elevation Fl at Foundation Fl into Tank Fl out of Tank Fl into 1a d-box FI I Bottom Row 1 High overflow Row1 Final grade over1 Fl into 2"“d-box Fl I Bottom Row 2 High overflow Row 2 Final grade over 2 Fl into 3'“d-box Fl I Bottom Row 3 Final grade over 3DApproval D Denial D Contact installer Date: D Update Master Sheet with review status. #Bedrooms Perc Rate Max system depth Sewer line- cleanout Tank Size;2-4”fl in to out Tank Filter,risers Pipe tank to d-box, between rows Leaching type Leaching length Leaching met MLSS met Distance on center Level-tie ends Serial-hlo 3"top Distances to wells Distances to water To water/utilities Distance to house/building To pool/accessoryToproperty line Fill needed-from where Variances needed Location Proposed (ft)OK 7§t Floor Elevation Fl at Foundation Fl into Tank Fl out of Tank Fl into 1a d-box FI I Bottom Row 1 High overflow Row1 Final grade over1 Fl into 2"“d-box Fl I Bottom Row 2 High overflow Row 2 Final grade over 2 Fl into 3'“d-box Fl I Bottom Row 3 Final grade over 3 Town of South Windsor —Health Department 1540 Sullivan Avenue,South Windsor,CT 06074 Phone:860-644-2511 ext.250 Fax:860-644-7280 SEPTIC SYSTEM CHECKLIST Water Service or Sewers Available? Print Assessor's Ca rd Print GIS Map Check USGS Info Perform Pit/Perc Design Recommendation Letter Plan Review Approval Permit to Construct Inspections As Built Permit to Discharge Page 1 of 1 Oatis,Heather From:Oatis,Heather Sent:Tuesday,October 13,2015 11:19 AM To:'ad bconstruction 1 @aol.com' Subject:1747 John Fitch Blvd Attachments:1747 JFB GIS.pdf Please see attached GIS map for 1747 John Fitch Blvd,it has the property tine measurements on it.Let me know if you need more detail and I’ll see what i can dig up. For the decommissioned well —No separation distance once it has been abandoned (per DPH). For the credit,side by side units gets the same credit as galleries,depending on the height.lfyou use the 12”high units,the credit goes up to 5.9 square feet.You can use the gallery chart to figure out which productwill getwhichcredit.The trench must be 6 feet wide. The last few inches ofthe pre—soak were taking forever.l have an appointment in a few minutes,so l’ll go back out there at the end of the day to do the perc and refill the hole.i should be able to send you my field notes tomorrow at some point. Heather Oatis,RS,HHS Environmental Health Specialist Town of South Windsor 1540 Sullivan Avenue South Windsor,CT 06074 Ph:860-644-2511 ext.250 Fax:860-644-7280 www.southwindsororv 10/14/2015 Town of South Windsor -Health Department 1540 Sullivan Avenue,South Windsor,CT 06074-2786 Phone:860-644-2511 ext.248 Fax:860-644-7280 DESIGN RECOMMENDATIONS FOR REPAIR OF SEWAGE DISPOSAL SYSTEM PROPERTY OWNER(S):US Bank STREET ADDRESS:1747 John Fitch B1Vd.,South Windsor RESIDENTIAL (#of Bedrooms):3 SEPTIC TANK:Install 1,000 gallon two—compartment septic tank with approved outlet filtor. LEACHING SYSTEM:495 square feet of effective leaching area required. Minimum Leaching System Spread (MLSS)need not be addressed due to suitable soil conditions of receiving soils. SPECIFIC INSTRUCTIONS: 1.Permit application to be completed and permit fees to be paid in full at time of application submission. 2.Installer’s construction plot plan (drawn to scale)to be submitted and approved by this office prior to issuance of permit to construct. 3.Plot plan must indicate location of proposed structure,water supply,septic system,embankments, watercourses,property lines,and existing and proposed finished grades.Benchmark to be set and indicated on plan.Note on plan that existing Septic System and well are to be properly abandoned. SIGNATURE:Ow .DATE:IOlHilS’ SITE INVESTIGATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM LOCATION DRAWING INCLUDING ALL TEST PITS AND PERCOLATION HOLES DESIGN RECO ATIONS/COMMENTSwell3v“\ir cNl “IVV %‘\¥r V{U\/\\/‘(& M WVM \f\r\()k\h£\ Mm LHF Wtwuundrta A’V QCVQ/HIM 2h l LA/ JIWM $t1'5Hm) Form completed by w ”MM /©(w S (Certlfied Local Health Agent or P E) Accuracy assured by (If P.E.completed form) (Certiiied Local Health Agent) Others present fpr si§inv(e stigation OVM NV(EngmeerLR (I’U\ developer,installer etc): SPECIAL CONDITIONS CONCLUSIONS Design Flow >2000 GPD Suitable for Sewage Disposal Public Water Supply Watershed Unsuitable for Sewage Disposal Probable High Groundwater Additional Investigation Req’d Slope >25 percent Wet Season Monitoring Req’d Perc Rate <1 min/inch Retest During Wet Season Perc Rate >30 min/inch Licensed Engineer Plan Req’d Ledge <5 feet below grade Other: Limited Suitable Area Open Watercourse or Wetlands Flood Plain /Seasonal Flooding Max.G.W.<36 inches below grade 1540 Sullivan Avenue,South Windsor,CT 06074 Phone:860-644-2511 ext.248 Fax:860-644-7280 SITE INVESTIGATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM Application/Permit #: Property Owner DATE:§U ‘§i$\\( Location \W U\/\ DEEP TEST PIT DATA/SOIL DESCRIPTIONS (Record all Test Pits) COMMENTS: GROUNDWATER TABLE (Near max,below max,etc.): SOIL MOISTURE (High,medium,low,etc.): DATE:$§PERCOLATION TEST DATA (Record all Perc Tests) \b\\"\ COMIVIENTS: 0'\A,b (Cjvvs‘k’l(’\k0i.d Q—®0\Lz\,(cIVW Town Of SOUth WINGSOI'-Health Department 36 PERC:/‘PERC:PERC:PERC: DEPTH: PRESOAK:go DEPTH:DEPTH:DEPTH:ion/oak PRESOAK:PRESOAK:PRESOAK: TIME READING TIME READING TIME READING TIME READING g’S‘E E:3’E "0L) 0‘1 ‘(0‘ \Z " ,,—I l\l lb H I:I“ WIN qi UV 0W?a \O 0 \lll HOV“ I R,V“ MIT“ 2,0“ ZO.WT PERC RATE:Lg PERC RATE: PERC RATE: TEST PITK /7 ‘2 TEST PIT:L /QT“TEST PIT:TEST PIT: bk;ZW‘3w p 50$ L b‘X\’O W\ I11"km?gai 5 x?XwXQmM 3(WW““ff/er \Nmo’w "'\/UZ fm N:S W E Mottles:Mottles:Mottles:Mottles: GW:GW:GW:GW: Ledge:Ledge:Ledge:Ledge: Roots:Z :‘\K Roots:\Zf“Roots:Roots: Restrictive:Restrictive:Restrictive:Restrictive: