HomeMy WebLinkAbout2019-5-30 - 189 Miller Road - Septic ApplicationTown of South Windsor —Health Department
1540 Sullivan Ave.,South Windsor,CT 06074 —Mailing Address
1530 Sullivan Ave.,South Windsor,CT 06074 -Office Address
Phone Number:(860)337-6173,Fax Number:(860)644-1930
APPLICATION FOR APPROVAL TO CONSTRUCT A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Application/Permit #:
To the Director ofHealth,Town of:5g?(jW/‘f /Date:6 50
Application is hereby made for an approval to construct a subsurface sewage disposal system for a:
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(Residential Building,Restaurant,Retail Building,etc.)
located at:I gg m I L‘Lé&RC)%~W’H IV)![\I 0%gl’
(Street Address,Lot Number,Subdivision Name,Map,Block,Lot,etc.)
New System Addition Repair Other vK‘I WW/
Owner A .Iw,Address [gy MMLé—g £C/Tel.No.
Installer?AUI/Iw Ffmt Address Q‘l‘l Wt W Lela Tel.No.365'6 §9‘43/5/
Gawain-e:it err away 09‘5‘7 ‘37 I}staller License No.
In accordance with detailed information stated below:
Application fee paid 7/073 Ob Signed Willi/L
(Owner or duly authorized representative)
GENERAL INFORMATION
Soil Tests Conducted (Date):Lot size sq.ft.
Area of Special Concern (Y/N):Ifyes,Reason(s):
Basis of Design (#of Bedrooms,Restaurant Seats,Building Size,etc):
Engineered Plan Required (Y/N):Ifyes.Name of Engineer:
Address of Engineer:
Design Plan Approved (YWN):Date ofApproved Plan:Revision Date:
Type of Water Supply Ifwell,has location been approved (Y/N):
Weli Driller‘s Name:Address:
OFFICE USE ONLY
Approval to Construct issued by:Date:
(Director of Health or Registered Sanitarian)
Signature:Title:RECEIVFr‘)
FEE PAIDMUQ CHECK it ZOQW DATE PAioz‘W‘Ma MAY 3 i 2mg
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HEALTH DEPARTMEM R ev.7/116/18
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Town of South Windsor -Hea!th Department
1540 Sullivan A\/e,,South Windsor,CT 06074 —Mailing Address
1530 SuHivan Ave.,South Windsor,CT 06074 -Office Address
Phone Number:(860)337-6173,Fax Number:(860)344-1 930
PERMIT TO DISCHARGE
Approval ls hereby Owen t0 0 %
(Property Owner )
Health Code Section l9-I3—B l 03e (h)to dischalge to a subsurface sewage disposal system iocated at
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(Street Address)
t in accordance with Public
in the town of Sa w s AMQ/.CT that will receive domestic sewage from a:
Residential building containing bedrooms.Single family (Y/N):
Restaurant containinU seats.
CommerCial/Oftice buildino prowdino square feet
Other structure as described.W’CW Law /SW/
Design Flow =gallons per day.Permitted Flow =gallons per day.
The design flow shall equal the permitted t‘lowg except for non—compliant repairs {See Section lV D)’
ln order to provide a sufficient factor ofsafety it is recommended that the average daily discharge not
exceed 2/3 ofthe permitted flow or gallons per day.
Qperatiom 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).Effluent filters
require periodic cleaning.Failure to 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
.lfyes.cleaning as necessary.Tank pump-outs tracked by local health department (’Y/N
stipulate pump—out requirements:
Special Requirements and Restrictions:l.In 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 (Y/N)
Date ofFinal inspection:klbl lc\Inspected Byzwkt/0&5
Permit Issuance issued bv W/Owl-q Q,S Title:gnu..\wK
(Direttor of Health or ReOIstered Sanitarian)
D ate;mamSignatur:'
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